Rollman BL et al. 2002 "A randomized trial using computerized decision support to improve treatment of major depression in primary care."
Reference
Rollman BL, Hanusa BH, Lowe HJ, et al. A randomized trial using computerized decision support to improve treatment of major depression in primary care. J Gen Intern Med 2002;17(7):493-503.
Abstract
"OBJECTIVE: To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression. DESIGN: Randomized controlled trial. SETTING: Academically affiliated primary care practice in Pittsburgh, PA. PATIENTS: Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria. INTERVENTION: PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: "active care" (AC), "passive care" (PC), or "usual care" (UC). MEASUREMENTS AND MAIN RESULTS: Patients' 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D less than or equal to7). Patients' mean HRS-D score decreased regardless of their PCPs' guideline-exposure condition (20.4 to 14.2 from baseline to 6-month follow-up; P < .001). However, neither continuous (HRS-D less than or equal to7: 22% AC, 23% PC, 22% UC; P = .8) nor categorical measures of recovery (P = .2) differed by EMR exposure condition upon follow-up. Care processes for depression were also similar by PCP assignment despite exposure to repeated reminders of the depression diagnosis and treatment advice (e.g., depression mentioned in greater than or equal to 3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P = .09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P = .3). CONCLUSIONS; Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients' 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care."
Objective
"To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression."
Type Clinic
Primary care
Type Specific
Internal medicine
Size
Small and/or medium
Geography
Urban
Other Information
The research site was a "large academically affiliated primary care practice in Pittsburgh, PA."
Type of Health IT
Electronic medical records (EMR)
Decision support system
Type of Health IT Functions
As part of routine practice, patients were screened for mental disorders by a self-administered questionnaire. When the system indicated that a patient had a mood disorder and met the other criteria of the study (and the patient passed further screening), "an interactive e-mail alert ... generated through [the] EMR system" was sent to primary care providers (PCP). If the PCP agreed with the diagnosis, the patient was included in the study and the PCP was randomly assigned to give "usual care" (no interventions), "passive care" in which the PCP was reminded to treat the patient's depression at each visit and given the opportunity to access a website describing guidelines for care, and "active care" in which the PCP was exposed to ... patient-specific advisory messages" based on guidelines and information previously entered by the provider about the treatment given. These PCPs were also encouraged to use the Web site.
Workflow-Related Findings
Patients whose PCPs were in the active care or passive care groups had more office visits and were likely to have more than three contacts with the PCP.
"PCPs respond quickly to electronic feedback of their patient's diagnosis of major depression, and that response rates and agreement with the diagnosis increased with repeated electronic reminders and as PCPs become more comfortable with feedback."
"The majority of patients were prescribed an antidepressant at both 3- and 6-month followup," but "few PCPs documented discussing depression with their patients 3 or more times, counseling them or advising them to see a mental health specialist for care."
"Contemporary EMR systems cannot automatically identify a mental illness, as they can an abnormal laboratory result or drug-drug interaction. Therefore, the need to systematically screen patients for depression either in person, by telephone, or following initiation of treatment is necessary, unless the EMR is programmed to expose physicians to treatment advice following entry of critical information into the system (e.g., physician prescribes antidepressant pharmacotherapy)."
Study Design
Randomized controlled trial (RCT)
Study Participants
Seventeen out of 19 primary care physicians were randomized into one of three EMR system exposure conditions. From a pool of 9,513 patients, 226 patients fit the eligibility criteria and consented to participate. The study's analyses focused "on the 200 patients (95 percent) who completed either our 3- or 6-month telephone assessment."