Patients with multiple chronic conditions are significantly less likely to receive treatment for depression at primary care practices that use electronic medical records (EMRs) compared with practices that do not use EMRs, new research shows.
Researchers at the University of Florida hypothesized that practices using EMRs would be particularly beneficial for complex patients with chronic conditions who are in need of depression treatment, offering greater efficiency in information sharing and delivery of care than those not using EMRs.
But the study of 3467 primary care practice visits by patients aged 18 years and older who were identified as having depression, which used data from the 2006 to 2008 National Ambulatory Medical Care Surveys, showed an opposite effect.
Although the use of EMRs did not affect depression treatment, defined as antidepressant prescription, referral to counselling, or both, in patients with 2 or fewer chronic conditions, the odds of receiving the treatment were significantly lower among patients with 3 or more chronic conditions (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.36 - 0.70; P > .001).
"We had been doing some research on the effect of health information technology on the delivery of care, and we expected use of EMRs would improve depression care by perhaps sending reminders of screening or treatment or help coordinate care," lead investigator Jeffrey S. Harman, PhD, at the University of Florida's College of Public Health and Health Professions, in Gainesville, told Medscape Medical News.
"We thought EMRs would be even more beneficial for patients who were complex with multiple conditions, but when we ran the analysis, we found the opposite of that."
The study is published in the August issue of the Journal of General Internal Medicine.
Learning Curve
The authors speculated that several factors could explain why a system designed to improve care could paradoxically be associated with as much as a 50% reduction in treatment.
For one thing, some research suggests that EMRs tend to have a heavier focus on biomedical information, as opposed to mental health issues. Other studies suggest that the use of EMRs can have the effect of interfering with psychosocial exchange, with the doctor spending more time interacting with the computer than the patient.
"We thought those 2 things might explain why we saw what we did, but to be clear, we have no way to know what caused the results we found, based on this data."
Psychiatrist Gabrielle Beaubrun, MD, whose work at Kaiser Permanente South Bay Medical Center, in Harbor City, California, focuses on integrating depression care into primary care, speculated that a diminished psychosocial exchange related to EMR use may have indeed factored into the findings, but that may have reflected the fact that the data came from the period 2006 to 2008, when many practices were only beginning to transition to EMRs.
"It's important to remember that back then, as psychiatrists, we were initially devastated by the idea of the electronic record," she told Medscape Medical News.
"We felt we were going to lose eye contact with the patient, and at first you do, but you have to get it back. You have to learn to let the patient interact with the machine."
"In our department, we demanded that our computers be set up on wheels so we could easily spin the screen around to show the patient what we're doing and to see what their graph looks like."
Patients, as well as physicians, have also been subject to a learning curve in the new age of EMRs, Dr. Beaubrun noted, "particularly the psychiatric patient, who is a bit wary of all of this stuff going into a computer, but they are gradually gaining comfort with it."
Time a Factor?
Whether or not EMRs are used, the idea of biomedical issues taking priority over mental health issues in primary care is an ongoing concern, but the fact that the patients in the study were diagnosed with depression indicates that clinicians at least got as far as spotting the problem.
The failure to take the next steps and offer treatment, particularly when there are 3 or more chronic conditions to address, may simply come down to a matter of time, Dr. Beaubrun noted.
"Primary care physicians, especially if they are contending with various other conditions, tend to view depression treatment as somewhat of a Pandora's box," she said.
"They may feel like, 'Oh no, I can't get into that whole antidepressant side-effects discussion.' Due to time constraints, they may just not want to go there."
A key solution, she says, is collaboration.
"The physician needs to work collaboratively with other healthcare workers and delegate someone to follow through on these types of things."
"You have to make delivering the right care easy. For instance, if the doctor needs to treat, go ahead and treat, and ideally, that can be accomplished with something like 1 click. Then someone else can do the 'Pandora's box' part of discussing the side effects with the patient."
Whereas clinicians may be inclined to believe that addressing the chronic conditions may, in itself, treat the depression, the assumption is risky, and the opposite can sometimes be the case.
"In psychiatry, we do encounter the idea from both patients and doctors that depression is a normal response to chronic illnesses, so why treat it, but in fact, clinical depression is not a normal response, and it does need to be treated," Dr. Beaubrun said.
"Ironically, the depression can be the lynchpin as to why so many other chronic conditions are happening," she added. "Treating the depression can in fact be central to getting the other conditions under control."
The authors and Dr. Beaubrun have disclosed no relevant financial relationships.
J Gen Intern Med. 2012;27:962-967. Abstract
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