Improved EHR Functionality Needed for Behavioral Preventative Care

Standard EHR functionality falls short in supporting behavioral preventative healthcare, according to a viewpoint published in JAMA.

EHRs are a powerful tool to access patient information, document clinical encounters, and alert providers of recommended health screenings. However, physicians less commonly address behavioral health screenings during clinical encounters.

A national quality improvement initiative funded by outlines changes needed for EHRs to support behavioral preventative health.

The Agency for Healthcare Research and Quality funded six primary care networks to facilitate improved screening and counseling of unhealthy alcohol use at 125 practices.

“Screening and counseling are recommended by the US Preventive Services Task Force (USPSTF), are easily delivered in primary care, and have demonstrated improvements in health outcomes but are sorely underdelivered in routine practice,” the authors wrote.

The primary care networks have provided practice facilitation to 67 practices. Of these practices, 40 had versions of a widely distributed EHR administered by their health system.

The versions of the EHR had six different pathways to document alcohol use and four different screening questionnaires, only one of which USPSTF recommends. No health system’s EHR scored the screening responses or alerted clinicians when a patient was due for screening.

In these EHRs, between two and eight clicks were needed to administer the screening. Another two to eight clicks were required for the clinicians to review the information.

“In one health system, the electronic workflow was so cumbersome, taking nearly 12 clicks to administer and 12 to review, that the system implemented a paper system to deliver the service,” the authors noted. “These examples highlight the lack of alignment between standard EHR functionality and evidence-based care.”

“Most health systems have had to improve EHR pathways through substantial tailoring after the baseline EHR was implemented,” they continued. “Local tailoring is valuable and necessary for meeting the needs of communities and practices; the balance of standardization and tailoring is ambitious and critical.”

However, they said that tailoring EHR workflows must start from an evidence-based, guideline-driven foundation that is easily accessible.

Further, standard EHR functionality should encompass patient-oriented screening. Patients could complete screening before their visit, and the EHR could present the scored results to the clinician, flagging results as abnormal if indicated.

“The EHR also should have programmed alerts that are automatically satisfied by patient completion and clinician review,” the authors continued. “Standard functions should include a registry to identify noncompleted screenings and to track patients who screen positive.”

Cancer screening alerts and automated completion are standard in most EHRs. However, due to the complexity of behavioral health recommendations, EHRs are not structured to support patient completion and improvement of patient outcomes.

“The challenge for digital health is to account for the several components of behavioral health interventions,” the authors wrote. “These preventive services are multistep processes that include screening for risks and then addressing identified needs through counseling or referral to services.”

“The EHR must mirror the multistep process and adapt as patient data are entered to provide counseling and referral support as at-risk individuals are identified, thereby ensuring the intervention is fully delivered,” they added.

The authors acknowledged that addressing EHR usability and interoperability across vendors is challenging. ONC has assisted in this effort by passing the 21st Century Cures Act, which includes usability and interoperability reporting requirements for EHR vendors. However, ONC could do more, they said.

“The ONC current EHR certification process, currently voluntary, could be made mandatory,” the authors wrote. “There could be further requirements developed as part of this certification for better standard implementation of preventive service reminders and management tools.”