Depression may go overlooked when physicians use electronic medical records, UF researchers find

Patients who have three or more chronic medical conditions are half as likely to receive depression treatment in primary care practices that use electronic medical records as they are in practices that use paper-based records, a new University of Florida study has found.

Electronic medical records, or EMRs, are generally thought to improve health care by allowing better coordination of care and increased accuracy in diagnosis and treatment. But the UF study raises questions about how computerized records systems could affect mental health care.

The findings appear in the August issue of the Journal of General Internal Medicine.

“While we don’t know why EMRs are associated with lower odds of depression treatment in patients with multiple conditions, we think that either they reduce the amount of interaction between patients and physicians or they focus a physician’s attention on physical health issues, pushing mental health issues off the radar screen,” said lead investigator Jeffrey Harman, Ph.D., an associate professor and the Louis C. and Jane Gapenski Term Professor of Health Services Administration at the UF College of Public Health and Health Professions.

Under the 2009 Health Information Technology for Economic and Clinical Health Act, the federal government offers incentive payments for Medicare and Medicaid providers who adopt electronic health record systems. Practitioners and hospitals must demonstrate “meaningful use” of the electronic health systems, that is, improvements in quality, safety and effectiveness of care. In 2011, 57 percent of office-based physicians were using EMRs, according to the National Center for Health Statistics.

The UF study team, which included Robert Cook, M.D., M.P.H., a UF associate professor of epidemiology and medicine, Christopher Harle, Ph.D., a UF assistant professor of health services research, management and policy, and Kathryn Rost, Ph.D., a University of South Florida research professor of mental health law and policy, analyzed 2006-2008 data from the National Ambulatory Medical Care Survey, a nationally representative sample of physician-office visits. They looked at all visits in which patients 18 and older received a depression diagnosis, a total of 3,467 visits, and noted whether the physician prescribed or continued antidepressant medication, mental health counseling or a combination.

Depression treatment in patients with one or two chronic conditions did not differ between EMR and non-EMR practices. But if patients had three or more conditions, they were half as likely to receive depression care at an EMR practice.

In previous studies of EMRs in inpatient settings, physicians reported that entering data is more time-consuming, as it requires clicking through many screens and system options. The result could be decreased psychosocial interactions between doctors and patients, Harman said.

“There is some evidence that typing these notes into the computer is actually reducing the amount of time that physicians and patients talk to each other during visits,” Harman said. “If the physician only has time to address two out of three conditions, depression may be the one that they’re not talking about.”

The researchers also theorize that the prompts and guidelines in EMRs are focused more on biomedical issues than mental health. Still, more research is needed to prove whether EMR use is responsible for the levels of depression care noted.

“Although the UF study is unable to determine a causal relationship between EMR adoption and decreased quality of depression care, identifying such an association is an important first step in better understanding the impact of EMRs on our health care system,” said Nir Menachemi, Ph.D., M.P.H., a professor of health care organization and policy at the University of Alabama at Birmingham School of Public Health, who was not involved in the UF research. “The next step will be to rule out that physicians who adopt EMRs are not somehow different from those who do not, which may explain the differences observed. Either way, I commend the team at UF for contributing valuable information to the ongoing debate on this critical topic.”