Rollman BL et al. 2001 "The electronic medical record."

Reference
Rollman BL, Hanusa BH, Gilbert T, et al. The electronic medical record: a randomized trial of its impact on primary care physicians' initial management of major depression. Arch Intern Med 2001;161(2):189-197.
Abstract
"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."
Objective

To describe the effect of electronic medical record (EMR)-based decision support on depression care.

Tools Used
Type Clinic
Primary care
Type Specific
Internal medicine
Size
Small and/or medium
Geography
Urban
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Electronic medical records (EMR)
Type of Health IT Functions
When screening indicated that the patient had major depression and fit other study criteria, the provider was notified with an interactive email alert generated through the EMR and an electronic letter. If the primary care provider agreed with the diagnosis, the patient was assigned to one of three conditions: usual care, passive care, or active care. In usual care, providers received no advice or reminders. In passive care, providers were reminded of the diagnosis and encouraged to treat the depression without information about how. The provider could click to access an intranet site with detailed advice on treating depression. In active care, providers "were exposed to 1 or more patient-specific advisory messages [that] were based on the AHRQ practice guideline and were modified for electronic dissemination via the EMR system. Most messages concluded with a suggestion that the clinician [click 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."
Context or other IT in place
An ambulatory electronic medical record system (EMR) system was installed 9 months prior to the study. Computer terminals were available in exam rooms, common clinic work areas, and physician offices.
Workflow-Related Findings
Patients whose physicians were assigned to the active or passive care groups were more likely than those who received usual care to agree with the diagnosis of depression at three days, one month, and 5 months after the alert. "Primary care physicians who agreed with the depression diagnosis by day 3 after notification more quickly initiated antidepressant pharmacotherapy than [providers] who agreed with the diagnosis only at a later time."
"Active care" PCPs more frequently responded to the electronic flags than did PCPs in the other groups.
"Although agreement with the diagnosis of depression typically precedes treatment of the disorder, we found that [providers] sometimes prescribed an antidepressant drug for their patients even when disagreeing with the depression diagnosis ... More troubling is that [providers] often did not provide an antidepressant treatment, including a timely follow-up appointment, even when they agreed with the diagnosis."
The time before active care physicians responded to the alert indicating that their patient had screened positive for major depression "was 1.6 times faster than that for passive care [providers]. Time [before the] response for usual care physicians was intermediate and did not differ significantly from the other 2 groups."
Study Design
Only postintervention with intervention and control groups
Study Participants
The study participants included 17 physicians. A total of 9,513 patients aged 18 to 64 years old were approached after screening surveys. Two hundred twenty-seven patients were protocol eligible and met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for depression. Of these 227 patients, 78 were assigned to active care, 78 to passive care, and 71 to usual care.