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Wednesday, September 5, 2012

EHR Software May Interfere With Recognizing Patient's Despression

Being "seen" by a medical professional...

When was the last time you were examined by your primary care physician (PCP)? And if you don't have a PCP, then when was the last time you were seen by any physician or medical professional, either as an outpatient or in an emergency room?  Was the medical professional using a computer to make notes about your current condition?  If you answered yes to the last question, then chances are the medical professional was using computer software to establish or update your electronic health records (EHRs).

What is an electronic health record?

There are many websites that offer a basic definition of an electronic health record. After reviewing a number of these, we offer the one found on Wikipedia:

"An electronic health record (EHR) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is theoretically capable of being shared across different health care settings. In some cases this sharing can occur by way of network-connected enterprise-wide information systems and other information networks or exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information."

It is important to note three phrases in this definition: evolving concept, theoretically capable of being shared, and may include a range of data. So we know that EHR software, like any software is deployed in steps or iterations (always being adapted or improved), with a goal that once a patient has an EHR the records can be immediately shared from doctor to doctor, across state lines, among different health care providers like hospitals, clinics and include a range of informational data, but there seems to be no mention of the data including the medical professionals' personal observations of the patient.  In other words, what does the medical profession "see" or intuit from the patient's physical appearance or behavior?

What are medical professionals concentrating on when they utilize EHR software? 

If you or a family member has been seen by a medical professional who is using EHR software there is a good chance that you wondered what the medical professional was not seeing, because their concentration was focused on the software. These professional sometimes carry the hardware, which is a portable computer, in one hand and complete the data fields with their free hand. If they are new to the software, you might notice them struggling to remember things like: do I hit the "enter" key, the "escape" key or the "tab" key; does this field accept only numbers and no special characters like - / #, can I find a diagnosis code that adequately describes the patient's overall condition?  Does the medical professional ask questions of the patients without making eye-contact, just keeping their eyes on the computer screen or even their back to the patient depending on whether or not the computer screen is bolted to a wall or on a swinging arm?

New study reports on what medical professionals are not seeing when using EHR software...

The results of a new study led by Jeffrey S. Harman, PhD, of the University of Florida and recently published in the Journal of General Internal Medicine may surprise you, or maybe not. According to the ModernMedicine website article, the following hypothesis was studied:

"...that because EHRs are designed to improve specialized care delivery, odds of depression treatment at practices with EHRs would be greater than at non-EHR practices."

Here is what the researchers determined after examining data from the 2006-2008 National Ambulatory Medical Care Survey:

  •  Depression treatment and mental health counseling were significantly less likely to be offered during visits to practices using EHRs.
  • Use of the technology also was significantly associated with reduced odds of treatment of depression during visits made by patients with three or more chronic conditions.
  •  EHRs were associated with half the odds of depression treatment, including antidepressant medication, whereas EHRs were not associated with the receipt of depression treatment in visits by patients with two or fewer chronic conditions.

Possible reasons for not recognizing patient depression...

The referenced study reports the following reasons for not recognizing depression and failing to offer treatment for depression and/or mental health counseling:

“[EHRs] encourage biomedical exchange between the physician and patient including discussion of medication. In contrast, [EHRs] have been observed to have a negative impact on psychosocial exchange, with screen gaze being inversely related to physician engagement. It is possible that the clinic workflows embedded in [EHRs] inadvertently encourage physicians to focus on these multiple physical problems and push depression treatment ‘off the radar screen,’ even after physicians diagnosed the condition.”

Can a patient help to improve the psychosocial exchange?

It is important to remember that depression can cause real physical changes and many patients don't realize that their physical symptoms could be caused by depression. Therefore, it is important that patients honestly and completely answer basic questions presented to them by the medical professional. For example:
  • Have you noticed a change in appetite?
  • Have you recently gained or lost weight?
  • How are you sleeping? Are you having trouble falling asleep or having trouble waking at a normal hour?
  • Do you feel tired? Are you always fatigued?
  • Do you have digestive problems, like constipation or diarrhea?
  • Do you have headaches?
  • Do you seem to have any kind of chronic pain? Including chest pain?
It is true that the answers to the questions posed might fit a number of conditions, other than depression. But if the medical professional poses a question, then it is incumbent upon the patient to answer the questions honestly and completely, offering details. The patient will not get the attention of the medical professional, including real eye-contact, if every question asked is answered matter-of-factly with: "Not really," or "A little," or "sometimes."

The bottom line is this: Help your health care provider to "see" you, to really get to know you, to recognize that what may seem like a little ache or pain might just be depression or some other debilitating mental health problem.  
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