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

To the Editor: Cifuentes et al¹ address the important issue of primary care behavioral health documentation and communication in electronic medical records. The article by Cifuentes et al reports frequent use of workarounds to respond to the inability of practices to integrate their electronic health records (EHRs). They note that at the end of the study, 2 of 11 practices were developing unified EHRs.

Though based on a limited convenience sample of practices, their conclusion leads readers to assume that in integrated care, EHR issues are not fully resolved. There are 3 concerns with the conclusions: EHR issues are not fully developed in many areas of medicine; integrated care cannot function without integrated EHRs; and multiple examples of well-developed, transparent, bidirectional EHRs exist in multiple integrated family medicine practices around the country.

EHRs are still in their youth (or adolescence), and have not yet grown into the hopes that many have for them. Templates for documentation, ease of use, interoperability, ability to extract data fields, use as part of care algorithms, and responding to the multiple needs for functionality for a broad range of users are among the current issues being considered. Applications for behavioral care within EHRs suffer the same and perhaps greater frustrations of all EHR users: how to use the available technology to meet their needs. These frustrations are often administrative rather than technical issues. The priority and pressure for developing integrated behavioral care systems is just emerging.

The degree of process integration among practices with co-located or integrated care varies widely. Summary data from the Practice Improvement Profile (PIP), a measure of the degree of practice integration derived from the Peek Lexicon, note that total scores on integration implementation show a median of 57.7 (range, 0–100), and that communication between behavioral health and primary care has a median score of 75 (range, 0–100). As we try to identify the core elements of integrated behavioral care, there are those who suggest that co-locating a clinician in a primary care practice is necessary, but is not sufficient to be considered integrated care.^2,3

There are multiple examples of practices and systems that include transparent, retrievable, templated, bidirectional behavioral communication in their EHRs. Work at Oregon Health Sciences University, Cherokee Health Systems (Tennessee), and Southeast Community Health Systems (Alaska) suggest that some early adapters have overcome most of the obstacles reported. In the recently funded Patient-Centered Outcomes Research Institute's Integrated Behavioral Health in Primary Care trial, the 40 participating practices must be developing integrated EHRs as a condition of participation.

In summary, a behavioral presence in EHRs is associated with the same growing pains as any other EHR user groups, amplified by the recency of integration development. The issue of whether co-located practices without EHR access, or integrated care with integrated EHRs, generate different outcomes is an important question that we hope to respond to in our trial, but until then, like most new initiatives, there is a range of responses to the challenges. Cifuentes et al¹ report a group of practices struggling with EHR integration, whereas many other practices have resolved these challenges and have functioning bidirectional EHRs.