Electronic health records are doing a poor job of capturing mental health diagnoses, visits, specialty care, hospitalizations, medications and other vital data, raising concerns about the potential for medical errors and risks to patient safety.

That’s the finding of an analysis by Boston’s Harvard Pilgrim Health Care Institute, which recently published its results in the Journal of the American Medical Informatics Association.

The study focused on diagnoses, visits, and hospital care for depression and bipolar disorder comparing information available in an EHR for Atrius Health’s Harvard Vanguard Medical Associates (HVMA), a multispecialty practice providing care to about 500,000 patients at more than 25 offices across eastern Massachusetts, with more complete data from insurance claims.

Researchers discovered that patients with depression and bipolar disorder averaged 8.4 and 14 days of outpatient behavioral care per year, respectively. However, 60 percent and 54 percent of this care, respectively, was missing from the EHR because it took place offsite.


In addition, total outpatient care days were 20.5 for those with depression and 25 for those with bipolar disorder, with 45 percent and 46 percent missing, respectively, from the EHR. Further, the EHR missed 89 percent of acute psychiatric services, while study diagnoses were missing from the EHR’s structured event data for 27.3 percent and 27.7 percent of patients, respectively.

“The continuing fragmentation of U.S. healthcare ensures that incomplete clinical data in primary site EHRs is a widespread problem,” concludes the study. “In this research, we found that the lack of integration, interoperability and exchange in U.S. healthcare resulted in a major EHR missing roughly half of the clinical information. Policymakers should put more focus on the quality and utility of health information and ways these can be improved, instead of simply tallying up EHR purchases and supposed capabilities.”

“Many people talk about EHRs as if they’re somehow complete, but they aren’t,” says Jeanne Madden, PhD, an instructor in Harvard Pilgrim Health Care Institute’s Department of Population Medicine. “Providers only know what happens at their own sites and what actually gets entered into their own EHRs. Insurers, meanwhile, tend to know pretty much the entire picture of the patient’s utilization.”

Madden notes that patients are typically assigned to a primary care provider site, which may have an EHR, but individuals frequently receive specialty care at other locations that do not (and usually cannot) share data with that EHR. Because health insurers maintain claims data on almost all drugs and health services received by a covered population, she contends that insurance claims can validate the completeness of mental healthcare data in provider EHRs.

Still, Madden asserts that behavioral health data is not the only clinical information that is missing from EHRs.

“While behavioral healthcare is unique, it is important to emphasize that our findings demonstrate that the problem of incomplete clinical data in the EHR is not limited to behavioral care,” states the study. “Rates of missing-ness were high among both behavioral events and overall events, both in and outside the hospital. Specialist care of all types is particularly likely to be underrepresented in a primary care EHR. HVMA is a multispecialty provider group; we expect that in many other simpler primary care settings, the extent of missing specialist care in the EHR would be far higher than at HVMA.”

Information relating to mental health or substance use disorders gets greater protection under both federal and state law than most other types of health records. These laws often make it difficult for providers to share records, even when patients want them to have access to their information. However, Madden does not believe that was a factor in the study.

What she says is more likely is that patients see this information as being sensitive and may protect their privacy by deliberately seeking behavioral care at a separate location from their somatic care “out of view” from the EHRs of their primary care providers.

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