News: Physicians don’t always document mental health in EHRs, study finds

For 27.3% of patients with depression and 27.7% of patients with bipolar disorder, providers did not integrate their diagnosis into their primary care electronic health record (EHR), according to a study published in the April 2016 Journal of the American Medical Informatics Association.

The study looked at insurance plan members ages 12 and over, assigned throughout 2009 to a large multispecialty medical practice in Massachusetts, with diagnoses of depression or bipolar disorder. The number of diagnoses was compared to data extracted from the primary care site’s EHR data. The EHR missed 89% of acute psychiatric services, the study says.

EHR implementation was intended to improve patient safety, research, and reimbursement. However, the majority of US health systems and electronic records are fragmented and do not share patient information. The study confirmed that EHRs inadequately captured mental health diagnoses, visits, specialty care, hospitalizations, and medications. Missing clinical information can result in medical errors and can affect research. CDI specialists can work with their IT department to ensure all aspects of a patient’s medical history and care—including mental health status—are incorporated into record templates.

Click here to download the full report.