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Clinical Decisionmaking

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Feedback from an electronic medical record can help primary care doctors improve their initial management of depression

Depressed patients who are treated by primary care physicians (PCPs) often receive inadequate treatment. This has been attributed in part to PCPs' low rate of recognizing depression and lack of awareness about and implementation of effective, guideline-based depression care. However, screening primary care patients for depression with a standard screen, informing PCPs of the results via electronic medical record (EMR), and presenting them with patient-specific treatment recommendations can influence their initial management of the disorder. These findings are from a recent study supported by the Agency for Healthcare Research and Quality (HS09421) and led by Bruce L. Rollman, M.D., M.P.H., of the University of Pittsburgh School of Medicine.

Dr. Rollman and his colleagues examined the impact of this approach on the initial management of 212 depressed patients by 16 internists. When a patient was identified by a computerized mood module as having major depression, PCPs were notified via an interactive e-mail alert generated through the EMR system and via an electronic letter signed by the study investigators. The doctor was asked to say whether he agreed, disagreed, or was unsure about the diagnosis. Reminders and scheduling of return visits were sent via E-mail to active care doctors, regardless of their agreement or disagreement with the diagnosis. Usual care doctors received no additional patient-specific advice or reminders of care during followup. Passive care PCPs were reminded of their patients' depression diagnosis on the paper encounter form generated for each patient visit, with suggestions to treat, but no details on how to treat.

About 65 percent of PCPs agreed with the diagnosis, 13 percent disagreed, and 23 percent were uncertain. Internists who agreed sooner with the depression diagnosis were more likely to make a medical chart notation of depression, prescribe antidepressant medication therapy, or refer the patient to a mental health specialist. Guideline exposure conditions (active, passive, and usual care) did not affect the agreement rate or treatments provided by the PCPs. However, active care doctors were less likely to ignore the electronic messages than doctors in the other two groups.

See "The electronic medical record: A randomized trial of its impact on primary care physicians' initial management of major depression," by Dr. Rollman, Barbara H. Hanusa, Ph.D., Trae Gilbert, M.A., and others, in the January 22, 2001 Archives of Internal Medicine 161, pp. 189-197.

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