Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care.

PURPOSE: This article describes the electronic health record (EHR)-related experiences of practices striving to integrate behavioral health and primary care using tailored, evidenced-based strategies from 2012 to 2014; and the challenges, workarounds and initial health information technology (HIT) solutions that emerged during implementation. METHODS: This was an observational, cross-case comparative study of 11 diverse practices, including 8 primary care clinics and 3 community mental health centers focused on the implementation of integrated care. Practice characteristics (eg, practice ownership, federal designation, geographic area, provider composition, EHR system, and patient panel characteristics) were collected using a practice information survey and analyzed to report descriptive information. A multidisciplinary team used a grounded theory approach to analyze program documents, field notes from practice observation visits, online diaries, and semistructured interviews. RESULTS: Eight primary care practices used a single EHR and 3 practices used 2 different EHRs, 1 to document behavioral health and 1 to document primary care information. Practices experienced common challenges with their EHRs' capabilities to 1) document and track relevant behavioral health and physical health information, 2) support communication and coordination of care among integrated teams, and 3) exchange information with tablet devices and other EHRs. Practices developed workarounds in response to these challenges: double documentation and duplicate data entry, scanning and transporting documents, reliance on patient or clinician recall for inaccessible EHR information, and use of freestanding tracking systems. As practices gained experience with integration, they began to move beyond workarounds to more permanent HIT solutions ranging in complexity from customized EHR templates, EHR upgrades, and unified EHRs. CONCLUSION: Integrating behavioral health and primary care further burdens EHRs. Vendors, in cooperation with clinicians, should intentionally design EHR products that support integrated care delivery functions, such as data documentation and reporting to support tracking patients with emotional and behavioral problems over time and settings, integrated teams working from shared care plans, template-driven documentation for common behavioral health conditions such as depression, and improved registry functionality and interoperability. This work will require financial support and cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters, and workforce educators.

Reports of persistent change in the clinical encounter following research participation: a report from the Primary Care Multiethnic Network (PRIME Net).

PURPOSE: Following anecdotal reports of unexpected patient and/or clinician behavior change in the primary care encounter in a previous study, we conducted this study to learn more about the short- and long-term effects on clinician and/or patient behavior from participation in a practice-based research network (PBRN) study. METHODS: Clinicians in two PBRN studies of Acanthosis nigricans were surveyed and interviewed 3 to 6 months following one study and surveyed 3 to 5 years following a second study. We gathered data on clinicians' reports of behavior change in the encounter, the persistence of those changes, and the likely causes of reported changes. RESULTS: Eighty-six percent of clinicians in the short-term and 79% in the long-term samples reported more frequent diagnostic efforts, and 68% and 54%, respectively, reported more frequent preventive counseling after participation in the studies. Interview data suggested that several factors contributed to this reported behavior change: increased clinician knowledge, availability of a feasible tool to support counseling, change in patient receptivity/motivation, and creation of a new context for counseling. CONCLUSIONS: Reports of behavior change in the primary care encounter associated with a PBRN study suggest that PBRNs may be effective vehicles for education, translation, and practice change in addition to their value in research.

Stop the escalators: using the built environment to increase usual daily activity.

BACKGROUND: Obesity is an epidemic in the United States. Two-thirds of the population is overweight and does not get enough exercise. Eastern cities are full of escalators that transport obese Americans to and from the subway. Walking stairs is a moderate activity requiring 3-6 metabolic equivalent tasks (METS) and burning 3.5-7 kcal/min. We determined the caloric expenditure and potential weight change of the population of one eastern city if all the subway riders walked the stairs rather than ride the escalators. METHODS: There are 5,000,000 daily journeys made on the New York City Subway. Subway entrances include a stairway or escalator of approximately 25 steps. Each step up requires 0.11-0.15 kcals; each step down requires 0.05 kcals. To lose one pound requires burning 3500 kcals. We assumed each rider made a round trip so about 2.5 million individual people ride the subway each day. RESULTS: By walking stairs rather than riding escalators, the riders of the New York Subway would lose more than 2.6 million pounds per year. DISCUSSION: The average subway rider would lose about one pound per year. While this may sound insignificant, in one decade the average subway rider would lose 10 pounds, effectively reversing the trend in the United States of gaining 10 pounds per decade. This conservative estimate of the number of stairs ascended daily means that subway riders might lose even more weight. We believe that this novel approach might lead to other public and private efforts to increase physical activity such as elevators that only stop on even numbered floors, making stairwells more attractive and well lit, and stopping moving sidewalks. The built environment may support small, incremental changes in usual daily physical activity that can have significant impact on populations and individuals.