Behavioral Science and the Electronic Health Record Demetrio Sanchez, Jr, MSW Roger Garvin, MD John Muench, MD, MPH

Goals Discuss/Exchange Ideas Concerning: In what ways are EHRs barriers to patient centered communication and behavioral health assessment and treatment? Are there possible work-arounds? In what ways can EHRs be used to facilitate behavioral health care and communication? Disclaimer: Please consider EPIC a surrogate for all EHRs. It’s all we had available.

Beh Med List-Serv Summer 2011 How many of you out there have residencies with EMRs? The reason I ask is that EMRs are so data-driven and force us to follow metrics, put numbers in boxes etc. They absolutely seem devoid of "the flavor of the patient" unless the practitioner takes the time to transcribe what patients say, and even then that is not part of the "structured data" that is the meat of the record. I ask all this because I wonder if that isn't making it harder for residents to see beyond the data and look at the patient in front of them.

Defining the patient with defined vocabulary

No genogram? www.genograms.org

Finding ways to use free text

Using the EHR to address unhealthy substance use

I IV III II Zones and interventions Low risk or abstention Referral Overview Referral Dependent IV III Harmful Brief intervention Risky II I Low risk or abstention

Depression and the EHR

Depression and the EHR Just having an EHR is not enough. 6 month time span ~ 200 patients with new diagnosis of depression 71% were prescribed medication < 4% screened for mania 26% had a PHQ-9 49% had some component of SIG-E-CAPS 23 % had no supporting evidence for diagnosis of depression.

Quality Indicators Only screen if you have systems to support the providers. Appropriate use of medications – not overuse Follow up in a timely manner Screening for mania before prescribing antidepressants. Ability to measure improvement

How can an EHR Help? Promote effective care – adequate documentation Teaching tool – decision support and reminders (mania screen) Tracking tool – in the EHR world free text is no better than a paper chart for gathering information.

Approach to Using the EHR How can you use flowsheets? How can you bring information to the provider? How can you streamline the process within the record? How can you track all those decisions you make with a complex disease like depression?

The Process at OHSU We will: Review flow sheets Review dotphrases for ease of documentation and decision support Review the use of smart data elements to give feedback to providers

Follow up documentation and decision aid

Integrating Team Based Behavioral Medicine Teams Facilitating Communication

Behavioral Health Communication Makes frequent team communication possible Easy to access all follow up types (Meds, Office Visits, RN Visits, Financial Specialist, BH Therapy) Notes don’t get lost “in the pile” of other paper charts. Ability to sort and filter information. Charts available to providers at all times. (ex. late night ER visits). Especially follow ups that have been done same day or even within a few minutes. Refill requests, acute crisis, med changes. Pt flags, treatment plans.

Behavioral Health Communication Communication with patients more efficient Take phone call from patient and pull chart right up. Reduces necessity to repeat story multiple times. Able to provide up-to-date information Less frustrating both ways.

Behavioral Health Interventions and the EMR More accurate BH interventions because more information is available to BH provider. (PCP treatment plan). BH can track patient’s health (weight, pain, diet, sleep, depression, substance use) to adjust BH treatment plan as needed. Review current meds to determine if patient taking as prescribed or having a reaction to.

Behavioral Health Interventions and the EMR More efficiency for warm handoff Quick access to insurance info (for MH referrals, etc.) Access to therapy sessions Behaviorist able to read what was worked on in previous sessions….or with another therapist. More efficient behavioral health case management Determine frequency of BH contact Check future appointments/schedule Correspond w/ pcp visit if pt has issues w/ transportation or has limited time.

Discussion What has been your experience with EHRs as a behavioral science teacher? Have your found other ways to use the EHR to enhance patient centered care and good communication?