Electronic Health Records and the Implementation of Person-Centered Care

Background: The majority of health care settings are transitioning to electronic health records to improve the quality of care.  Policies such as the Affordable Care Act and the Health Information Technology Act have provided significant infrastructure support for agencies to integrate technology into their care delivery.  Another key health care reform priority has been delivering person-centered care, which honors individual preferences and values.  This mixed methods study explores how use of an electronic health record (EHR) impacts the implementation of person-centered care within community mental health clinics (CMHCs).

Methods:  The study sample was four CMHCs participating in an NIMH-funded RCT of person-centered care planning (PCCP). These sites were implementing PCCP and actively utilizing an EHR as part of routine care. Uptake of PCCP was measured by a quantitative fidelity measure, assessing the person-centeredness of individual consumer service plans (N=283). ANOVA and Bonferroni multiple comparison tests were used to analyze site level differences in uptake of PCCP.  Using an inductive, constant comparative technique, two coders analyzed qualitative data from 8 provider focus groups and 9 interviews with agency leadership, which explored the barriers and facilitators to PCCP implementation.  Thematic analysis identified themes across and within sites related to EHR use.

Results:  Results from the ANOVA indicated significant site level differences in the uptake of PCCP (F(3,95)=6, p<.001) and the multiple comparison tests found one site demonstrated significantly higher levels of PCCP. EHRs emerged as a salient, common factor affecting implementation.  Providers reported that default EHR interfaces were not designed to promote individualized care, which impeded efforts to implement PCC.  EHRs were burdensome and time consuming to navigate deterring providers from developing genuinely person-centered care plans. Providers were also restricted by boilerplate care plan formats that made it difficult to create individualized treatment goals. Ability to customize the EHR system varied between sites, and appeared to play a critical role in overcoming these obstacles. Agencies with lower PCCP uptake were ‘locked in’ to their current EHR interface, while the agency with greater PCCP uptake had flexibility to adjust their system or develop work around options to document individualized care.     

Conclusions and Implications:  Overall, this study indicates that EHR technology plays an important role in the uptake of a new practice and that there was a tension between EHR design and the delivery of person-centered care. Agencies that had lower levels of PCCP had EHRs that were hard to navigate and unable to accommodate the level of individualization demanded by PCCP.  The agency that was more successful in delivering PCCP had an EHR that could be modified to allow for individualization.  This confirms prior findings from implementation research, that in addition to training providers, agencies must align their procedures with a practice innovation.  In terms of person-centered care, when designing their EHRs agencies must balance the need to standardize documentation with the need to individualize care.