EHR Transition Disrupted Pediatric MH Screenings

The implementation of an electronic health record (EHR) system was associated with a significant decline in the rate of behavioral health screenings conducted at a large pediatric practice in Massachusetts, according to a new study published in the March Psychiatric Services.

Karen Hacker, M.D., M.P.H., of Cambridge Health Alliance and the Institute for Community Health led a team of researchers from Seattle’s Group Health Research Institute and the Harvard Pilgrim Health Care Institute’s Department of Population Medicine in assessing the practice’s screening rates before, during, and after the transition from paper to EHR reporting. The system the practice adopted was the Epic-Care EMR system.

The practice’s seven pediatricians serve a diverse population of approximately 6,000 patients, of whom an average 180 per month are eligible for behavioral health screenings. The researchers noted that 54 percent of the clinic’s patients are nonwhite, 40 percent are publicly insured or self-paying, and 31 percent are non-English speakers. Roughly one-third of the patient population is below age 5.

The practice began conducting behavioral health screenings in December 2003 using the Pediatric Symptom Checklist (PSC) for children aged 4.9 to 16 and the PSC-Youth Report for children aged 14 to 18.

Prior to implementation of the EHR system in March 2005, patients or their caregivers would fill out paper screening forms for discussion with and scoring by their pediatrician, who would subsequently complete the form and insert it into the patient’s medical record.

In the first nine months of conducting screenings, which the researchers defined as the study’s baseline period, the rate of behavioral health screenings, though variable, rose from approximately 70 percent to 91 percent. During this time, nurse management staff enhanced the screening process by conducting previsit medical-record reviews and attaching paper screening forms to the charts of those patients they deemed eligible for screenings.

The practice’s transition to the EHR system was preceded by six months of planning and preparations, with all staff members receiving 40 hours of off-site training. During this period—from October 2004 to March 2005—the pediatric clinic’s screening rates fell from about 84 percent to 64 percent.

To help the clinicians adjust to the new system, patient visits were halved during the first week of implementation and reduced by 25 percent in the second week. Additionally, in-house trainers were available on site. Yet despite these measures, the conversion was associated with a further drop in screening rates, with only 50 percent of eligible patients screened during the first month of electronic record reporting.

The screening process remained the same following implementation of the EHR system, but the physicians were now tasked with entering results from the paper screening into a field-driven electronic database. The researchers also noted that paper screening forms were no longer attached to patients’ medical records prior to their visits, making it more difficult for front-desk staff to quickly identify which patients needed behavioral screenings.

Over a period of three years, and with medical assistants eventually assuming responsibility for the entry of screening data, the practice’s behavioral health screening rates slowly returned to near baseline levels, reaching 82 percent by April 2008.

The study was supported in part by a grant through the Integrated Health and Behavioral Health Care for Children, Adolescents, and Their Families program administered by the Health Resources and Services Administration’s Maternal and Child Health Bureau. The Harvard Pilgrim Health Care Foundation, the National Institute of Mental Health, and the Health Maintenance Organization Mental Health Research Network also provided partial support, as did the Health Maintenance Organization Research Network Centers for Education and Research on Therapeutics.

Harvard Catalyst and the Harvard Clinical and Translational Science Center provided additional consultative support for the study, while Harvard University and affiliated academic health care centers provided additional funding.