Documentation, communication and information exchange emerged as common EHR integration challenges among primary care practices and behavioral health centers attempting to integrate care activities. Researchers tracked 11 Colorado practices over a three-year span and reported findings in the September-October edition of the Journal of the American Board of Family Medicine.
The study involved eight primary care practices, all using a single EHR, and three community mental health centers, which used two different EHRs — one to document behavioral health and one to document primary care information. Researchers found “mismatches between capabilities of existing health IT systems and the clinical tasks practices needed to perform.”
Site visits conducted during the course of the study revealed three main EHR challenges common among participating practices:
1) Clinicians newly hired to help integrate care (e.g., psychologists in primary care practices and nurse practitioners in community mental health centers) generated data not previously documented or tracked by existing EHRs.
2) Integrated teams needed shared care plans to coordinate tasks, but weren’t able to see when each other’s tasks had been completed. EHRs typically lacked templates to support shared care plans.
3) EHRs were not interoperable with other EHR systems or with tablet devices used at behavioral health facilities to administer screening surveys.
In response, the observed practices resorted to workarounds in the areas of “double documentation” and duplicate data entry; scanning and transportation of documents; reliance on patient or clinician recall for inaccessible clinical documentation; and use of freestanding tracking systems.
Part of the study examined how practices and EHR vendors adapted to the observed challenges and workarounds. These solutions surfaced “generally after two to three years of experimentation and learning,” according to the study report, and included customized EHR templates, EHR system upgrades and unification of EHR systems.
Practices that created specific data fields and templates within existing EHRs were able to more easily document and track relevant behavioral and physical health information related to screenings, referrals, treatment and followup. However, the study report says:
“Creating customized EHR templates was time-consuming and required dedicated HIT staff working collaboratively with behavioral health centers and primary care providers. Practices that did not have access to these resources were not able to create customized templates as readily, or had to pay EHR vendors to do so.”
Five practices upgraded their EHRs to obtain improved screening templates, reporting interfaces and interoperability with other electronic devices. However, these upgrades required practices to make large financial investments — which were not covered by the terms of the study grant.
Four practices took steps to unify the different EHRs operating at the primary care and behavioral health ends of the care spectrum. These efforts ranged from full-scale transition to a unified EHR to the building out of interfaces to pull data from different systems.
Overall, some practices moved beyond workarounds toward more permanent solutions that helped them get more out of the EHR systems. However, EHRs still lack features essential to supporting integration in these areas:
“... Documenting and tracking longitudinal data, working from shared care plans and [providing] template-driven documentation for common behavioral health conditions such as depression. EHRs also had poor registry functionality and could not be electronically linked with freestanding registries, making it difficult for practices to monitor and track patients with specific behavioral health conditions, medication regimens and those receiving specialty mental health services outside the practice.”
The researchers noted that practices without dedicated HIT resources may need to find new ways to pay for new template development and system upgrades. And although some funding may be available through meaningful use incentives, that program does not adequately account for “all the basic data elements and reporting functions needed for effective integrated behavioral health and primary care,” according to the study report.
“Relief will require financial support and cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters and workforce educators,” the report concludes.