Purpose: 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.Conclusion: 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. (J Am Board Fam Med 2015;28:S63-S72.)

Objective: This study was conducted to test the effectiveness of a theory-based interactive voice response (IVR) intervention to improve adherence to controller medications among adults with asthma.Methods: Fifty participants aged 18 to 65 years who had a physician diagnosis of asthma and a prescription for a daily inhaled corticosteroid, attended a baseline visit and a final visit 10 weeks later. Participants randomized to the intervention group received 2 automated IVR telephone calls separated by one month, with one additional call if they reported recent symptoms of poorly controlled disease or failure to fill a prescription. Calls were completed in less than 5 minutes and included content designed to inquire about asthma symptoms, deliver core educational messages, encourage refilling of inhaled corticosteroid prescriptions, and increase communication with providers. Adherence was tracked during 10 weeks, with objective measures that included either electronic monitors or calculation of canister weight. Participants completed the Asthma Quality of Life Questionnaire, the Asthma Control Test, and the Beliefs in Medications Questionnaire (BMQ) during both visits.Results: Adherence was 32% higher among patients in the IVR group than those in the control group (P ‫؍‬ . Patients often do not adhere to treatments for chronic health conditions, with the consequence that many conditions are poorly controlled. In the treatment of asthma, fewer than half of prescribed daily controller medication is typically taken by patients.1,2 In a report about refill patterns among 5500 patients with asthma, only 43% filled their inhaled corticosteroid more than once during 12 months. 3 In another study, each 25% decrease in refilled medication was accompanied by a doubling of the hospitalization rate. 2 Adherence rates among children are similarly poor 4,5 and remain so even in the face of recent exacerbation. 6 Considerable attention has been directed at changing health behavior and increasing adherence to treatments for chronic health conditions. The World Health Organization in 2003 published a call for action to improve treatment adherence across diseases, continents, and cultures, 7 and the This article was externally peer reviewed.

OBJECTIVE AND DESIGN: This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline‐concordant acute‐phase care for patients with current major depression. PARTICIPANTS AND SETTING: Two hundred thirty‐nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment. Sixty‐six (27.6%) patients identified as failing to meet criteria for guideline‐concordant treatment 8 weeks following the index visit were the focus of this analysis. METHODS: The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline‐concordant acute‐phase care. This information was used to develop a checklist of barriers to depression care. The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider. Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient. Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles. RESULTS: The cluster analysis produced a 5‐cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%), and health care system problems (8 patients, 12.9%). The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient‐centered barriers. Physician‐centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points. Twenty‐eight percent of the patients not initiating guideline‐concordant acute‐stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters. CONCLUSIONS: Current interventions fail to address barriers to initiating guideline‐concordant acute‐stage care faced by more than a quarter of depressed primary care patients. Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care. Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns. Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care. Because few untreated patients improve without acute‐stage care, additional work is also needed to develop new intervention components that address these barriers.