title: Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (MC, DF, PD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, RG, DJC); Oregon Rural Practice-based Research Network, Portland (MD); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC). maribel.cifuentes@ucdenver.edu.
authors.forename: Maribel
authors.initials: M
authors.lastname: Cifuentes
authors.affiliation: From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (MC, DF, PD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, RG, DJC); Oregon Rural Practice-based Research Network, Portland (MD); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC).
authors.forename: Melinda
authors.initials: M
authors.lastname: Davis
authors.affiliation: From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (MC, DF, PD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, RG, DJC); Oregon Rural Practice-based Research Network, Portland (MD); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC).
authors.forename: Doug
authors.initials: D
authors.lastname: Fernald
authors.affiliation: From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (MC, DF, PD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, RG, DJC); Oregon Rural Practice-based Research Network, Portland (MD); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC).
authors.forename: Rose
authors.initials: R
authors.lastname: Gunn
authors.affiliation: From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (MC, DF, PD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, RG, DJC); Oregon Rural Practice-based Research Network, Portland (MD); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC).
authors.forename: Perry
authors.initials: P
authors.lastname: Dickinson
authors.affiliation: From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (MC, DF, PD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, RG, DJC); Oregon Rural Practice-based Research Network, Portland (MD); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC).
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D003156:Community Mental Health Services / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004282:Documentation / Q000379:methods; D057286:Electronic Health Records / Q000458:organization & administration*; D006801:Humans; D001523:Mental Disorders / Q000628:therapy; D011216:Practice Management, Medical / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D014481:United States
keywords: Behavioral Medicine; Delivery of Health Care; Electronic Medical Records; Integrated; Medical Informatics; Mental Health; Primary Health Care