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The Electronic Medical Record
A Randomized Trial of Its Impact on Primary Care Physicians' Initial Management of Major Depression
Bruce L. Rollman, MD, MPH;
Barbara H. Hanusa, PhD;
Trae Gilbert, MA;
Henry J. Lowe, MD;
Wishwa N. Kapoor, MD, MPH;
Herbert C. Schulberg, PhD
Arch Intern Med. 2001;161:189-197.
ABSTRACT
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Background Inadequate treatments are reported for depressed patients cared for
by primary care physicians (PCPs). Providing feedback and evidence-based treatment
recommendations for depression to PCPs via electronic medical record improves
the quality of interventions.
Methods Patients presenting to an urban academically affiliated primary care
practice were screened for major depression with the Primary Care Evaluation
of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility
criteria and completed a baseline interview. They were cared for by 16 board-certified
internists, who were electronically informed of their patients' diagnoses,
and randomized to 1 of 3 methods of exposure to guideline-based advice for
treating depression (active, passive, and usual care). Ensuing treatment patterns
were assessed by medical chart review and by patient self-report at baseline
and 3 months.
Results Median time for PCP response to the electronic message regarding the
patient's depression diagnosis was 1 day (range, 1-95 days). Three days after
notification, 120 (65%) of 186 PCP responses indicated agreement with the
diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty.
Primary care physicians who agreed with the diagnoses sooner were more likely
to make a medical chart notation of depression, begin antidepressant medication
therapy, or refer to a mental health specialist (P<.001).
There were no differences in the agreement rate or treatments provided across
guideline exposure conditions.
Conclusions Electronic feedback of the diagnosis of major depression can affect
PCP initial management of the disorder. Further study is necessary to determine
whether this strategy, combined with delivery of treatment recommendations,
can improve clinical outcomes in routine practice.
INTRODUCTION
MAJOR depression is among the most common problems encountered in primary
care settings, affecting 6% to 10% of all patients who present for care.1 Depressed patients experience at least as much physical
and social dysfunction from this disorder as those with chronic physical conditions
such as hypertension, diabetes, arthritis, and back pain.2, 3, 4
Moreover, depression worsens the prognosis for other coexisting medical problems
and may even lead to suicide.5, 6
In 1990 alone, the direct and indirect costs associated with depression in
the United States exceeded $40 billion.7
Primary care physicians (PCPs) currently provide most treatment for
depression.1 However, poorer than expected
outcomes are consistently reported for depressed patients treated by PCPs.8, 9 This is thought to be partially related
to PCPs' low rate of recognizing depression and a lack of awareness about
and implementation of effective, guideline-based depression care.10, 11 Screening primary care patients for
depression, informing PCPs of the results, and then presenting patient-specific
treatment recommendations should overcome these informational deficits. However,
randomized clinical trials12, 13, 14
that have tested a screening and feedback strategy using a letter or note
in the patient's medical chart addressed to the PCP have failed to demonstrate
any significant improvement in clinical outcomes. These findings may have
resulted from inadequate physician attention to the feedback process, physical
separation between the written assessment and the patient's medical chart,
an excessive interval between the PCP's contact with the patient and when
he or she received notice of the psychiatric diagnosis, or failure by the
physician to follow up and effectively treat the patient in a timely manner
after receiving feedback.
Although the computer's potential to assist clinical decision making
was recognized in the 1950s,15 recent advances
in software and hardware technology, combined with reductions in the cost
of computing power, have brought affordable electronic medical record (EMR)
systems with decision support capabilities into the average physician's practice.
At their most basic level, EMRs can facilitate the organization and rapid
retrieval of information by serving as digital repositories for physicians'
notes and laboratory reports as well as patients' problem lists, medications,
allergies, and essential sociodemographic and contact data. Furthermore, some
EMR systems are capable of presenting physicians with organized information
in a timely manner and prompting them to provide appropriate clinical care.16 This strategy is particularly effective when the
physician must specify an action taken in response to the notification and
when initial nonresponders receive multiple messages.17, 18
Indeed, physicians using EMR systems with these features are more likely to
order recommended preventive and disease management care than practitioners
using traditional, nonautomated medical records19, 20
and have been found to make fewer prescription,21
test,22 and antibiotic ordering errors.23 Routine use of EMR systems in clinical practice could
also lead to a decrease in medical errors by eliminating illegible medical
records and prescriptions. Furthermore, changes in clinical routines can be
introduced into widespread practice through periodic software updates of existing
protocols, thereby facilitating PCPs' ability to remain current and provide
higher-quality care for a variety of conditions, including psychiatric disorders.
Although it is estimated that just 5% of US physicians use computerized patient
records in their office practices (David W. Bates, MD, Brigham and Women's
Hospital, Boston, Mass, e-mail communication, May 30, 2000), increased applications
may be anticipated given pressures to provide high-quality care at reduced
cost, continued consolidation of health care providers into organizations
sufficiently large to support the costs of installing and maintaining these
systems, and steady declines in the real costs of computer technology.24
Because PCPs are often ineffective at caring for patients with major
depression, the EMR's technical features make it an attractive but untested
vehicle for facilitating its treatment in routine primary care practice. Therefore,
we investigated (1) how rapidly PCPs respond to an interactive message presented
via a commercially available EMR system informing them that one of their patients
had screened positive for major depression; (2) how often PCPs agree or disagree
with the depression diagnosis when presented electronically; (3) clinical
characteristics of patients and professional characteristics of PCPs associated
with agreement with the diagnosis; and (4) PCPs' initial treatment recommendations
after EMR feedback of the patient's depression diagnosis. Data regarding these
practice patterns are highly pertinent for other investigators considering
use of an EMR system to improve the quality of care for depression in the
ambulatory medical sector.
PARTICIPANTS AND METHODS
STUDY SITE
This research was conducted at the main urban primary care practice
affiliated with the University of Pittsburgh School of Medicine, Pittsburgh,
Pa. This practice is staffed by 19 PCPs board certified in internal medicine
who typically care for 10 to 15 patients per half day without assistance from
house staff.
Nine months before implementing the electronic guideline for major depression,
Logician (version 4.2; MedicaLogic, Beaverton, Ore)25
was installed as the ambulatory EMR system for the practice. After each patient
encounter, physicians type their clinical impressions directly into the EMR
or dictate them into the medical center's central transcription service for
later transcription and uploading into the EMR. In addition, physicians enter
and maintain electronically their patients' problem and medication lists.
Primary care physicians can access their patients' medical information
via computer terminals placed in examination rooms, common clinic work areas,
or their own office located separate from the practice site. They use these
terminals to obtain instant access to their patients' medical records. Primary
care physicians are also given a printed summary of each patient's medical
problems, medications, and various care recommendations on a paper encounter
form generated by the EMR system for each office visit (Figure 1).
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Figure 1. Patient encounter form. A printed
summary of the patient's medical problems, medications, and active care recommendations
is generated for each patient encounter, which can also be viewed online.
This patient recently started taking fluoxetine for a recurrent episode of
major depression.
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PARTICIPANTS
Primary Care Physicians
Using a protocol approved by the institutional review board of the University
of Pittsburgh, we recruited PCPs approximately 1 month before patient recruitment.
Several of us (B.L.R., W.N.K., and H.C.S.) presented highlights of the Agency
for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health
Care Policy and Research) Depression Panel's Guideline26
and then introduced the study to PCPs at an hour-long journal club–style
conference. All 17 PCPs eligible to enroll in the study (B.L.R. and W.N.K.
were ineligible to participate) subsequently provided informed consent to
enroll and completed a self-report baseline assessment packet. Primary care
physicians were then stratified by their number of half-day clinic sessions
per week and then within each strata were randomly assigned to 1 of the 3
exposure conditions before the start of patient recruitment (see the "Intervention
Conditions" subsection). Because of the nature of our interventions, PCPs
were not masked to their assignment condition.
Primary Care Patients
All patients aged 18 to 64 years presenting to the study site were screened
for major depression using the self-administered Patient Questionnaire (PQ)
portion of the Primary Care Evaluation of Mental Disorders (PRIME-MD),18 which they completed as part of routine practice
before meeting with their PCP. If the patient screened positive for a mood
disorder on the PQ and had (1) no obvious dementia, psychotic illness, or
unstable medical condition; (2) 2 or fewer positive responses on the CAGE
alcohol screening questionnaire27 included
on the PQ; and (3) no language or other communication barrier that would limit
the patient's ability to participate in the research assessments, a research
assistant sought the patient's written consent to administer the mood module
component of the PRIME-MD to ascertain the presence of a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,28 diagnosis of major depression.
When the PRIME-MD mood module assessment indicated that the patient
had a current major depression, the research assistant asked the patient to
provide a second written informed consent for the full clinical protocol.
Each patient's clinical eligibility was confirmed with a detailed baseline
telephone assessment and a medical chart review by one of us (B.L.R.). In
addition to the criteria described in the previous paragraph, the protocol
also required that the patient (1) have a Hamilton Depression Rating Scale
score of 12 or greater, (2) report no alcohol or other substance abuse disorder
within the past 2 months, (3) have no history of bipolar disorder, (4) have
no active suicidal ideation, (5) be medically stable as determined from medical
record review and the baseline telephone assessment, (6) have no plans to
leave the study practice within the next 6 months, and (7) not be receiving
treatment at baseline for depression from a mental health professional.
PROCEDURE FOR ELECTRONIC NOTIFICATION OF THE DEPRESSION DIAGNOSIS
When a patient was identified by the mood module as having major depression,
PCPs were notified via an interactive e-mail alert ("flag") generated through
the EMR system and via an electronic letter signed by the study investigators.
These messages generally were transmitted to the PCP within 1 business day
of the patient being diagnosed as having major depression. Primary care physicians
were asked to indicate whether they "agreed," "disagreed," or were "unsure"
of the diagnosis of major depression on the PRIME-MD. They were also asked
to electronically "sign" the letter to acknowledge its receipt, much as they
would acknowledge a consult letter from another health care professional.
When the PCP indicated agreement with the psychiatric diagnosis, a researcher
entered "major depression" into that patient's electronic problem list and
forwarded a flag to the clinic's scheduling secretary. This message requested
that the patient be scheduled or rescheduled for a follow-up visit with the
PCP within 4 weeks of the PRIME-MD assessment, if such an appointment was
not already entered into the practice's electronic scheduling system. If the
PCP electronically expressed uncertainty about the depression diagnosis, the
researcher replied with a new flag inquiring whether the patient could be
scheduled to return within 4 weeks so that the PCP could again consider the
diagnosis. When the PCP indicated disagreement with the depression diagnosis,
another interactive e-mail message was sent after the patient's next visit.
Reminders were automatically generated if the PCP did not respond to an e-mail
message within 3 business days. The diagnosis of "major depression" was added
to a patient's electronic problem list only when the PCP agreed with the PRIME-MD
diagnosis.
INTERVENTION CONDITIONS
"Usual care" clinicians and PCPs in the other treatment arms who disagreed
or were unsure of a patient's depression diagnosis received no additional
patient-specific treatment advice or reminders of care during follow-up.
"Passive care" PCPs were provided a reminder of their patients' depression
diagnosis on the paper encounter form (Figure
1) generated for each patient visit. This message encouraged the
PCP to treat the depressive episode but offered no details about how to do
so. The message also suggested that the PCP mouse-click on a computer desktop
icon if he or she wanted further advice for treating depression. Doing so
launched a Web browser offering the PCP detailed advice for treating depression
based on the AHRQ's depression treatment guideline26
from an Intranet site we developed for use in this study. Passive care PCPs
were not exposed to any other intervention prompts.
"Active care" PCPs who agreed with the diagnosis were exposed to 1 or
more patient-specific advisory messages on the paper encounter form (Figure 1) generated for viewing at the time
of the clinical encounter. These messages were based on the AHRQ practice
guideline and were modified for electronic dissemination via the EMR system.
Their content varied in keeping with a PCP's earlier actions as entered into
the EMR system (eg, the patient was prescribed an antidepressant medication).29 The clinician could also view these messages online
at any time. Most messages concluded with a suggestion that the clinician
mouse-click on the computer desktop icon to obtain further treatment advice
from our Intranet site. Active care PCPs were also exposed to prompts offering
to schedule a follow-up appointment with their study patients whenever the
interval between follow-up appointments exceeded twice that recommended by
the AHRQ guideline for a given treatment phase, as determined by a researcher's
review of the clinicians' encounter notes.
PATIENT ASSESSMENT
All participants were contacted by telephone shortly after recruitment
to confirm their protocol eligibility and to conduct a standardized research
assessment. The interviewer (T.G.) was masked to the randomization status
of a patient's PCP. These interviews assessed depression severity (using the
Hamilton Depression Rating Scale),30 quality
of life (using the 12-Item Short-Form Health Survey),31
perceived social support (using the Medical Outcomes Study-social support
scale),32 type of treatment received at the
baseline visit for depression, and sociodemographic information. The type
of depression-specific treatment recommended to the patient by the PCP and
the number and timing of follow-up visits were abstracted directly from the
EMR by another investigator (B.L.R.) who was also masked to the randomization
status of a patient's PCP. This information was confirmed by patient self-report
at the baseline assessment and during the 3-month follow-up telephone interview.
PHYSICIAN MEASURES
Shortly after protocol enrollment, PCPs completed questionnaires providing
sociodemographic information, self-reported comfort using the EMR, and knowledge
about and attitudes toward treating depression. Response time of PCPs to the
electronic messages alerting them to their patients' PRIME-MD depression diagnoses
and agreement with them were recorded by the investigator (T.G.) who had contacted
the PCP and was masked to the randomization status of the patient's PCP.
STATISTICAL ANALYSES
The primary outcomes in this analysis of the EMR's utilization were
(1) days to PCP response; (2) PCP initial response to notification of their
patients' depression diagnosis; and (3) what actions the PCP took to treat
the depressive episode. All statistical analyses were completed on an intent-to-treat
basis using statistical software (Statistical Product and Service Solutions
v9.0; SPSS Inc, Chicago, Ill, or Stata v6.0; Stata Corp, College Station,
Tex).
Our sample size estimates were based on a 3-group design to detect a
difference in proportion recovered of 30% (65% vs 35%), with  = .05
(2-tailed) and ß = .20. Because the PCP was our unit of randomization
and patients were nested under the PCP, we considered the dependence of observations
and applied Donner's adjustment formula [1 + (n - 1) ], where n is the number of patients nested under a physician and
is the estimated intracluster dependence.33
With a conservative of 0.05, we estimated before the start of the
study that 72 patients were required in each group.
Patient variables across the 3 methods of exposing PCPs to guideline-based
treatment advice were compared using  2 analyses that corrected
for the nesting of patient under each physician. Comparisons among intervention
arms in time to response to and time to agreement with the initial diagnosis
flag were analyzed using discrete survival methods.34
Univariate and multivariate correlates of the PCP's first response were identified
by polychotomous logistic regression, which also corrected for the nesting
of patients under each physician. The same statistical method was also used
in comparing patients whose PCP agreed with the diagnosis within 3 days or
1 month of electronic notification or did not agree within 1 month. Physician
actions after agreement (or disagreement) with the diagnosis were compared
using separate logistic regressions.
The method used for regression modeling was to test for the significance
of a variable first as a univariate correlate and then as a correlate, with
intervention group added as an interaction term. Any variable that was a significant
univariate correlate or whose interaction with intervention group was significant
was included in a backward stepped multivariate model. Variables considered
in the modeling included all patient variables portrayed in Table 1 and the PCP variables of years of experience, extent of
depression training, number of clinic sessions per week, sex, attitudes toward
treating depressed patients and the EMR system, and randomization status.
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Table 1. Patient Demographic and Clinical History Variables*
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RESULTS
We approached 9513 patients aged 18 to 64 years between April 1997 and
December 1998 and asked them to complete the PRIME-MD PQ (Figure 2). Of 8302 patients (87%) who did so, 1331 (16%) had positive
screening results for a mood disorder (PQ+). After a research assistant performed
a preliminary review of PQ+ patients' medical records, 736 (55%) were judged
to be protocol eligible, 597 (81%) completed the mood module, and 345 (58%)
met Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, criteria for a current episode of major depression.
Of this group, 77 were protocol ineligible, 12 declined to enroll in the treatment
phase, and we were unable to contact 8 patients to perform a baseline assessment
and to confirm protocol eligibility despite multiple telephone calls and follow-up
postcards. The remaining 227 patients were included in 1 of our 3 guideline
exposure conditions in keeping with their PCP's earlier randomization assignment.
Consequently, 78 patients were assigned to active care, 78 to passive care,
and 71 to usual care. However, 15 patients (7%) later withdrew their consent
to participate when contacted for a telephone assessment.
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Figure 2. Patient recruitment scheme. PQ
indicates the Patient Questionnaire portion of the Primary Care Evaluation
of Mental Disorders (PRIME-MD); PQ+, positive screening results for a mood
disorder on the PQ; and PCP, primary care physician.
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The analyses in this study are restricted to the 212 patients who completed
the baseline telephone assessment. Measures of physician visits and mental
health specialist use were available from 194 participants who completed a
3-month follow-up telephone interview. Table 1 presents demographic and clinical characteristics of study
participants. Their mean age was 44 years (range, 19-64 years), 69% were women,
and 72% were white. Although our 3 study groups were balanced on most demographic
measures, active care patients were more likely to be men (P = .001) and passive care patients were more likely to be married
(P = .04). There were small but statistically significant
differences among the groups in the measures of depression severity, social
support, and quality of life. The 3 groups were similar in their rates of
a current comorbid anxiety disorder and past treatment for depression.
Although 17 PCPs were randomized into the 3 study arms, only 16 had
patients enrolled in our study. One of the PCPs provided only demographic
information. The other 15 completed most of the prestudy forms. The 3 study
arms yielded physician groups that were similar in demographic and experience
variables and in perceptions of depression care and the EMR (Table 2). Approximately half of the PCPs (8 of 15 respondents) reported
some exposure to continuing medical education courses for treatment of depression,
and three quarters (11 of 15) expressed comfort discussing depression care
with their patients. Moreover, most study PCPs were comfortable using the
EMR system for patient care.
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Table 2. Characteristics of PCPs Included in the Study*
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RESPONSE TO ELECTRONIC NOTIFICATION OF THE PRIME-MD DIAGNOSES
Primary care physicians responded to the electronic flag notifying them
of their patients' PRIME-MD depression diagnosis within 1 business day 54%
of the time and within 3 business days 88% of the time. The median response
time in the passive care condition was 2 days, but it was only 1 day for all
groups combined (range, 1-95 days). Time to any response for active care physicians
was 1.6 (95% confidence interval, 1.1-2.1) times faster than that for passive
care PCPs. Time to any response for usual care physicians was intermediate
and did not differ significantly from the other 2 groups.
AGREEMENT WITH THE DIAGNOSIS OF MAJOR DEPRESSION ON THE PRIME-MD
Three days after notification, 120 (65%) of 186 PCP responses indicated
agreement with the diagnosis of major depression generated by the PRIME-MD,
24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Figure 3 displays the similarities in temporal
pattern of agreement across study arms. At 3 days there were no statistically
significant differences among PCP study arms in rate of agreement with the
depression diagnosis. However, active care PCPs more frequently responded
to the electronic flags than did PCPs in the other 2 groups (95% response
rate vs 77% and 90% for passive care and usual care PCPs, respectively).
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Figure 3. Percentage of patients whose primary
care physician agrees with the depression diagnosis.
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One month after notification, PCPs agreed with 147 (71%) of the depression
diagnoses, disagreed with 34 (16%), and were unsure about 27 (13%). There
were no significant differences in response rate or content of response at
1 month across intervention groups. Overall, PCPs responded to 208 (98%) of
the electronic messages presented. The final PCP response was received on
day 154 after electronic notification of the depression diagnosis. At this
point, PCPs agreed with 166 (78%) of the depression diagnoses, disagreed with
36 (17%), and remained unsure about 10 (5%).
Multivariate analyses of PCP responses to the PRIME-MD diagnosis of
major depression 3 days after notification are displayed in Table 3. Primary care physicians were less likely to disagree with
the depression diagnosis if the patient had previously been treated for depression.
However, PCPs with more than 10 years of clinical experience were more likely
to disagree with the diagnosis. Female PCPs tended to be more unsure of the
depression diagnosis than their male colleagues. Primary care physicians also
ignored the initial EMR message regarding their patients' depression diagnoses
less frequently if they were randomized to the active care study arm, they
had more clinic sessions per week, or their patient was enrolled after the
first 6 months of patient recruitment. When analyzed across all nonagreement
responses, PCPs did not accept the depression diagnosis for patients with
higher levels of baseline mental health quality of life (12-Item Short-Form
Health Survey mental health composite score) and social support. Although
PCP comfort with treating depressed patients and participation in continuing
medical education for depression were associated with their response pattern,
these variables correlated with having more years of clinical experience and
were not significant in multivariate analyses. A model that included patient-level
variables correctly predicted 56% of PCP responses ( = 0.08; P<.01). Adding PCP-level variables to the predictive
model provided little additional accuracy (correct predictions, 59%;
= 0.18; P<.001).
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Table 3. Patient and PCP Characteristics Associated With Response to
Depression Diagnosis 3 Days After Notification*
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TREATMENT OF DEPRESSED PATIENTS
When PCPs agreed with the depression diagnosis they typically documented
depression in their progress notes and initiated treatment. Table 4 displays PCP actions by time to agreement with the diagnosis.
Patients whose PCPs agreed with the diagnosis within 3 days received or were
offered antidepressant pharmacotherapy significantly more often than those
whose PCPs agreed later or did not agree at all. Patients in the 1-month agreement
group were significantly more likely than the early agreement group to have
a follow-up visit during this period, as recommended by the AHRQ Depression
Panel's Guideline.26 However, this pattern
may reflect our attempts at having PCPs schedule an early follow-up appointment
with patients if they were unsure about the depression diagnosis.
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Table 4. Primary Care Physicians' (PCPs') Actions to Treat Depression
for Initial, Delayed, and No Agreement With the Depression Diagnosis by 1
Month*
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COMMENT
Primary care physicians responded quickly to electronic feedback of
their patients' diagnosis of major depression on the PRIME-MD. Response rates
and agreement with the diagnosis increased with electronic reminders and as
study recruitment progressed. Primary care physicians who agreed with the
depression diagnosis by day 3 after notification more quickly initiated antidepressant
pharmacotherapy than PCPs who agreed with the diagnosis only at a later time.
However, agreement with the diagnosis did not affect the rate at which patients
were referred to a mental health specialist. Furthermore, PCPs initiated treatment
for depression even when they disagreed or were unsure about the diagnosis,
although at a lower rate than for patients about whose diagnosis they agreed.
However, after controlling for agreement status, there were no significant
differences by exposure of PCPs to intervention conditions in the initial
treatments for depression offered to patients.
Investigators12, 13, 14
previously reported the results of screening primary care patients for major
depression and then informing their clinicians of the diagnosis. However,
this is the first study to our knowledge that informed the PCP of the depression
diagnosis electronically or required the physician to acknowledge its receipt.
Although PCP assignment to an AHRQ treatment guideline exposure condition
did not affect level of diagnostic agreement (Figure 3), active care PCPs were less likely to ignore the electronic
messages than were physicians in the other 2 groups. Primary care physicians
were also less likely to ignore messages presented to them after the first
6 months of recruitment, suggesting a "learning curve" for the electronic
feedback mechanism.
This study is also the first to analyze board-certified PCP rates of
agreement with the PRIME-MD diagnosis of major depression. Although all study
patients were experiencing at least a moderate level of depressive symptoms
(Hamilton Depression Rating Scale score  12), PCPs disagreed with or were
unsure about the depression diagnosis generated by the PRIME-MD for approximately
one third of the patients 1 month after notification. Primary care physician
agreement with the diagnosis 3 days after EMR notification was associated
with poorer patient scores on the 12-Item Short-Form Health Survey mental
health composite score but not the Hamilton Depression Rating Scale in the
multivariate model (Table 3).
Furthermore, experienced clinicians were more likely to rely on their own
judgment and to disagree with the depression diagnosis generated by the PRIME-MD
than were their less experienced colleagues.
It is tempting to speculate that electronic feedback of the depression
diagnosis to PCPs can improve the speed with which the condition is recognized
and appropriate treatment is begun. Indeed, higher rates of antidepressant
pharmacotherapy were found in patients whose PCPs quickly agreed with the
depressive diagnosis despite lack of a relation between diagnostic agreement
and the severity of a patient's depressive episode. Thus, routine use of EMR
systems may lead to pharmacotherapy being implemented at a guideline-recommended
dosage and duration. This speculation is supported by findings from randomized
trials in which EMRs increased the frequency with which recommended preventive
and illness-specific care was provided17, 19, 20, 23, 35, 36, 37, 38, 39, 40, 41, 42, 43
and patient outcomes were improved.20, 23, 35, 39, 41, 42
Yet, we cannot confirm that electronic feedback of the diagnosis results in
faster initiation of appropriate therapy because earlier studies of nonelectronic
feedback of the diagnosis to PCPs did not describe the interval between feedback
and the initiation of treatment. Moreover, screening and feedback of the depression
diagnosis to PCPs via nonelectronic means has also been demonstrated to increase
the recognition of mental disorders and the likelihood that an intervention
will be initiated.14, 15, 16
Thus, further study of the EMR remains necessary to examine whether electronic
feedback of the depression diagnosis and speedy initiation of treatment will
increase PCP adherence to guideline-based treatment recommendations and improve
clinical outcomes (eg, quality of life, work productivity, and reduced health
services utilization).
Although agreement with the diagnosis of depression typically precedes
treatment of the disorder, we found that PCPs sometimes prescribed an antidepressant
drug for their patients even when disagreeing with the depression diagnosis
(Table 4). We did not require
PCPs to indicate why they disagreed with the diagnosis to minimize the protocol's
intrusiveness. Still, we can speculate that some clinicians may be reluctant
to diagnose major depression because it can offend patients.44
More troubling is that PCPs often did not provide an antidepressant treatment,
including a timely follow-up appointment, even when they agreed with the diagnosis.
The findings from this study must be interpreted with a recognition
that it was conducted within a single, large, academically affiliated primary
care practice. Although our main analyses corrected for the nesting of patient
outcomes under each physician, our findings must be considered cautiously
because each study group contained only 5 or 6 PCPs. This may have limited
our power to detect significant differences among intervention groups or permitted
the actions of a single PCP to unduly impact group outcomes. Also, investigators
using other commercially available EMR systems may obtain different results.
Given the trend toward rapid advancements in the capabilities of computer
software, replication of this clinical trial using other contemporary EMR
systems is necessary. Still, because EMRs cannot automatically capture the
diagnosis of a mental illness as they can for an abnormal laboratory result
or a drug-drug interaction, the need to systematically screen patients for
depression in person,45 by telephone46 or after initiation of treatment47
will remain for the foreseeable future.
We believe that our findings are generalizable to nonacademic group
practice settings that use EMR systems in a similar manner as we have described.
First, unlike many other studies conducted in academic settings, all of our
study PCPs were board certified. House staff and their patients, including
those precepted by attending physicians, were protocol ineligible. Second,
our study site serves a diverse population that included individuals with
lower to lower-middle income, residents of ethnic and African American neighborhoods,
faculty and staff of the University of Pittsburgh, and others enrolled in
a variety of insurance plans. Third, we know of no published study indicating
that patients with psychiatric distress treated by "academic" PCPs achieve
clinical outcomes dissimilar from patients treated by "nonacademic" PCPs.
In conclusion, electronic notification of the depression diagnosis can
affect the PCP's initial management of major depression, particularly when
the PCP agrees with the diagnosis. Further study is necessary to determine
whether this strategy, combined with delivery of patient-specific guideline-based
treatment recommendations, can improve adherence to an evidence-based treatment
guideline and clinical outcomes for depression in routine primary care practice.
AUTHOR INFORMATION
Accepted for publication July 11, 2000.
This work was supported by grant R01 HS09421 from the Agency for Healthcare
Research and Quality, Rockville, Md.
Presented in part at the 13th NIMH International Conference on Mental
Health Problems in the General Health Sector, Washington, DC, July 12, 1999.
From the Division of General Internal Medicine, Center for Research
on Health Care (Drs Rollman, Hanusa, and Kapoor), the Center for Biomedical
Informatics (Dr Lowe), and the Department of Psychiatry, Western Psychiatric
Institute and Clinic (Mr Gilbert and Dr Schulberg), University of Pittsburgh
School of Medicine, Pittsburgh, Pa.
Corresponding author: Bruce L. Rollman, MD, MPH, Center for Research
on Health Care, University of Pittsburgh School of Medicine, 200 Lothrop St,
Suite E-820, Pittsburgh, PA 15213-2582 (e-mail: rollmanbl{at}msx.upmc.edu).
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