EHR tools improve screening rates, but not universally used

Electronic health record tools designed to help improve screening rates on several behavioral health scales succeeded at increasing screening rates but were only implemented in one-third of the practices studied, according to research recently published in the Journal of the American Board of Family Medicine.

Perspective from Elmer V. Bernstam, MD

“Research supports the inseparability of behavioral health care and medical care and strong evidence shows that integration, bringing behavioral and medical care together, improves clinical outcomes, improves patient experiences of care, and reduces health care costs,” Katelyn K. Jetelina, PhD, MPH, an assistant professor in the department of epidemiology, human genetics, and environmental sciences at the University of Texas School of Public Health, and colleagues wrote.

“Less well known is how to effectively deliver integrated care in routine primary care practice,” they added.

Researchers implemented the Behavioral Health e-Suite in six federally qualified community health centers. This suite consists of EHR tools that addressed the needs of behavioral health clinicians integrating into primary care practices and the process of care involving Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 screening The community health centers were matched in a 1:1 ratio based on patient panel characteristics and the community health center’s location.

Jetelina and colleagues found that the suite’s implementation improved Patient Health Questionnaire-9 screening, but only two clinics fully utilized the Behavioral Health e-Suite; two did not utilize it at all and two partially utilized it. Practice capacity, willingness to change, extent of planning, and level of self-efficacy were among the reasons cited for the varying degrees of use.

“These latter two clinics likely represent the norm among primary care clinics in the United States, which suggests the need for evidence-based implementation support strategies, such as practice facilitation or expert consultation, to assist with tool implementation,” they wrote.

Researchers added that a one-tool-fits-all approach will not work for behavioral health clinicians integrating into primary care practices.

“Our study has important lessons for clinics planning to use health [information technology] tools for integration. In order for clinics to invest the time to implement the Behavioral Health e-Suite, these tools must fit their needs,” Jetelina and colleagues wrote. – by Janel Miller

Disclosures: The authors report no relevant financial disclosures.

Perspective

Elmer V. Bernstam, MD

In this study, researchers created a tool that facilitated certain kinds of activities (ie, work by “behavioral health clinicians” in primary care teams). The practices chosen for the intervention were heterogeneous — some did not even have a behavioral health clinician embedded in their primary care team, and there were different kinds of such clinicians (licensed clinical social worker vs. clinical psychologist vs. one with a master’s degree in social work).

I would not expect that the tool, in and of itself, would necessarily improve outcomes across a range of settings. The researchers did not have control over clinical processes. Thus, their tool might affect processes, but could not really define/enforce new processes. As an example, if I were asked to increase screening using PHQ-9 (one of the screening questionnaires tracked in this study), I would want to define a clinical process and a person who is in charge of this at each clinic. For example, a nurse would be responsible for screening every patient. Thus, a process might be: patient arrives, nurse checks if patient has been screened, if not then screen and record. In the absence of a clinical process change (perhaps supported by a tool), I would expect modest change in outcomes.

The integration of behavioral health into primary care is important and the researchers deserve credit for trying to improve the status quo. The patients seen in safety net clinics (where this study was done) probably have greater behavioral health needs compared to a non-safety net (eg, well-insured) population. The methods included complementary qualitative and quantitative approaches, and statistical analyses that were particularly sophisticated (eg, using propensity scoring). In addition, validated tools (eg, Picker Institute Scale) were used whenever possible (as opposed to making up their own measures), and this was a thoughtful study design (eg, looking at patient characteristics in the control vs. intervention clinics).

Elmer V. Bernstam, MD

Professor of internal medicine and biomedical informatics,

The University of Texas Health Science Center at Houston

Disclosures: Healio Family Medicine was unable to determine Bernstam's relevant financial disclosures prior to publication.

Sources/Disclosures

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Source:

Jetelina KK et al. J Am Board Fam Med. 2018;doi:10.3122/jabfm.2018.05.180041.