Missing clinical and behavioral health data in a large electronic health record (EHR) system

Abstract

Objective: Recent massive investment in electronic health records (EHRs) was predicated on the assumption of improved patient safety, research capacity, and cost savings. However, most US health systems and health records are fragmented and do not share patient information. Our study compared information available in a typical EHR with more complete data from insurance claims, focusing on diagnoses, visits, and hospital care for depression and bipolar disorder.

Methods: We included insurance plan members aged 12 and over, assigned throughout 2009 to a large multispecialty medical practice in Massachusetts, with diagnoses of depression (N = 5140) or bipolar disorder (N = 462). We extracted insurance claims and EHR data from the primary care site and compared diagnoses of interest, outpatient visits, and acute hospital events (overall and behavioral) between the 2 sources.

Results: Patients with depression and bipolar disorder, respectively, averaged 8.4 and 14.0 days of outpatient behavioral care per year; 60% and 54% of these, respectively, were missing from the EHR because they occurred offsite. Total outpatient care days were 20.5 for those with depression and 25.0 for those with bipolar disorder, with 45% and 46% missing, respectively, from the EHR. The EHR missed 89% of acute psychiatric services. Study diagnoses were missing from the EHR's structured event data for 27.3% and 27.7% of patients.

Conclusion: EHRs inadequately capture mental health diagnoses, visits, specialty care, hospitalizations, and medications. Missing clinical information raises concerns about medical errors and research integrity. Given the fragmentation of health care and poor EHR interoperability, information exchange, and usability, priorities for further investment in health IT will need thoughtful reconsideration.

Keywords: electronic health records; health care systems; health information exchange; mental disorders; validation studies.

Figure 1:

Average number of days with outpatient care per patient in 2009, total and behavioral, and percentage of care days occurring at external provider sites, according to insurance claims. In the analyses below, we defined “behavioral” as having any mental health specialist provider. We conservatively classified days that included care at both the EHR site and external providers (∼3% of total) as occurring at the EHR site. Although all subjects were assigned to HVMA for their primary care, we conservatively classified care occurring beyond HVMA in the broader Atrius provider network as occurring at the EHR provider site, because Atrius providers share a single EHR. For all categories of care shown below, average days at the EHR site as derived from claims were identical to average days at the EHR site as derived from EHR data (average EHR counts not shown).