Challenges to depression care documentation in an EHR.

BACKGROUND AND OBJECTIVES: Patients with depression most frequently present in primary care. Electronic health records (EHR) have the potential to improve depression care through improved clinical documentation and information exchange. This report provides an example of how an EHR can fail to capture important information regarding depression care.
METHODS: A 6-month baseline period in 2009 was defined to identify ambulatory patients age 18 or older in the EHR with an ICD-9 coded new depression diagnosis. Data was abstracted electronically, and charts were reviewed by hand for patient demographics and to assess the clinical documentation of depression screening, diagnosis, and treatment practices among four community-based family medicine clinics.
RESULTS: Electronic abstraction of baseline data identified 200 adult patients with a documented new diagnosis of depression. Review of charts by hand was required to obtain clinical documentation of screening (9% of patients), use of diagnostic tools (73%), discussion of treatment options (83%), medication treatment (71%), and follow-up characteristics (75%).
CONCLUSIONS: Despite having a robust EHR, we encountered significant challenges finding documentation of depression care, which also made it difficult to track and evaluate the implementation of evidence-based treatment. Clinical documentation in the EHR needs to be simplified and standardized if data extraction and exporting processes of clinician performance data are to become efficient and routine practice.