An Electronic Future?
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- Madlyn Bishop
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1 An Electronic Future? Behavioral and mental health providers are currently excluded from the meaningful use incentives for electronic health record adoption but there s hope that will change By Lindsey Getz In February 2009, President Obama signed into law a stimulus package that included more than 100 pages dealing directly with funding to stimulate the adoption of electronic health records (EHRs). Dubbed the Health Information Technology for Economic Clinical Health (HITECH) Act, $19 billion had been committed to advance HIT use through monetary incentives with up to $44,000 available per eligible physician and potentially millions for eligible hospitals that could demonstrate meaningful use. Driven by those incentives, many practices have adopted EHRs and discovered the benefits include efficiency and even improved quality of care. That s all great news for hospitals and physicians but behavioral health providers were shocked to find they were excluded from these incentives. While a push has been made for change, as it currently stands, the HITECH Act does not extend those incentives to behavioral health providers. Frankly, I was horrified that we were left off, says Virna Little, PsyD, LCSW- R, SAP, senior vice president, psychosocial services and community affairs for The Institute for Family Health, headquartered in New York City. The government is putting all this effort into integration and coordinated care and then has left half of the providers off the grid. Mental and behavioral health providers are critical to patients overall care and those records should be integrated into the electronic infrastructure. Still, without the ability to help behavioral health providers with some dollars to build that electronic infrastructure, it likely won t happen. Currently, the only behavioral health providers who are eligible are psychiatrists who are also MDs. Organizations that provide integrated care (both physical and mental) may also have eligible physicians. But overall, behavioral health facilities are not eligible and many say that means they will not be inclined to adopt EHRs despite the potential benefits to their practices and patients. I ve been on both the medical side and the behavioral health side and the fact is that the implementation process, steps, procedures, and planning are the exact same whether it s medical or non-medical, says Michael Lardiere, LCSW, vice president health information technology and strategic development, the National Council for Community Behavioral Healthcare in Washington DC. We have the same support needs. There are huge workforce issues that arise with EHR implementation, and that s also true whether it s medical or non-medical. But we not only don t have access to monetary incentives, we don t have access to the support programs available to assist with implementation. While behavioral health providers are in serious need of workflow support during EHR adoption same as the medical community the exact issues that arise during implementation are different. That s because the medical community does operate in a much different manner than behavioral and mental health providers.
2 Both medical and behavioral health providers need support, but the differences come in surrounding issues of workflow within the practice, says Lardiere. Workflow operations are just different in behavioral healthcare. Oftentimes, behavioral health providers offer many different levels of care from outpatient to residential or training programs and all of that needs to be taken into account. Also, when a patient goes to a medical practice, he is usually seen by an assistant who stages the patient before the doctor even comes in whereas with behavioral health, you often see the clinician right away. Those workflow differences are important in terms of how the EHR is set up and right now they are designed more for medical use. Another key difference between medical care and behavioral health has to do with confidentiality laws. This has the potential to be a great barrier to adoption. In fact, many are concerned that unless their questions over the privacy of mental health and substance abuse information are addressed, that portion of the medical record will never be fully integrated into an overall electronic network. If you re a substance abuse organization and you share information outside of your own organization, there are different confidentiality requirements that have to be followed, says Lardiere. Currently, the health information exchanges (HIEs) are not technologically sophisticated enough to process those added requirements. It s another example of EHRs not really being designed to fulfill the needs of the behavioral health community. Extending Incentives, Increasing Adoption Of course, without the incentives being extended to behavioral health providers, all of this may be moot as adoption rates will remain at a minimum. Without the meaningful use dollars available to behavioral health providers like social workers, there are just too many economic barriers for most practices to adopt these systems, says Jeff Richardson, MSW, executive director, Mosaic Community Services, a non-profit organization specializing in serving individuals and families with limited resources in the Baltimore Metropolitan area. Most behavioral health providers are not working in large hospital systems with a lot of capital to roll this out. Purchasing the system, having the staff available to implement it, and updating the infrastructure are all very expensive endeavors. Most of the behavioral health community is already under-capitalized and you need capital in order to even purchase the systems. We need the incentive of those meaningful use dollars. Richardson says there is so much involved during implementation that he calls it a near impossible task to complete without help. It s not just purchasing the system, but all of the time and money involved in actually putting it into place is a massive undertaking, he says. Take an organization like mine where we have 700 employees but only 25 are eligible for meaningful use dollars. That s a near impossible task. Little says that without sufficient funding, behavioral health practices are going to wind up with small-scale and ineffective systems that simply don t meet the proper needs. Practices not only need funding surrounding implementation but also technical assistance in selecting a system, she says. You don t know what you don t know meaning many of these practices don t even know what questions to ask when it comes to selecting a system. My advice is to seek out mental health providers who have been successful in implementing a system and find out everything they can.
3 While most professionals often assume that purchasing the software is the biggest expense, Richardson says that s in fact the least expensive part of EHR adoption. The software itself is the cheapest part of the process, he says. It s being able to afford support along the way in learning how to use it and training staff. The financing of these systems without broader resources available is a major challenge and really slowing the adoption of EHRs among behavioral health providers. And in terms of behavioral health as a profession, that puts us even further behind in the bigger healthcare discussion an area where we ve fought hard to be included. Big Benefits Besides the benefit of being included in the overall healthcare discussion, and aiding with the integration of medical and behavioral health, implementing electronic medical records offers other benefits to providers. Little is personally a huge fan of EHRs and has been on a system since I feel like my ability to see the benefits of EHR utilization come from having worked with a comprehensive and sophisticated electronic system that has reporting and clinical functions all-in-one, she says. It s incredible what you can do around care measures when you have a good system in place. The medical community has already found that, despite challenges, the benefits of EHRs have great potential including improved safety and quality of care, convenience for patients, and even overall better outcomes. Patients of practices that have implemented EHRs and offer patient portals appreciate being able to access their own medical records online. Patients of behavioral and mental health practices could see some of these same benefits, while an EHR system can help the overall practice run more effectively. While behavioral health providers are currently still excluded, there has been some legislative push toward policy that would add mental health providers to EHR incentives, and that includes two key pieces of legislation. A bill was introduced by Senator Sheldon Whitehouse that would expand the Medicare and Medicaid EHR incentive programs to include mental health workers and facilities. This bill, the Behavioral Health Information Technology Act of 2011 (S. 539) seeks to ensure that health IT is available to behavioral health, mental health, and substance abuse treatment professionals and facilities. Sen. Whitehouse has said that mental health care is a critical component of our healthcare safety net and believes that allowing such providers to access the available incentives will improve patients overall care. By expanding the use of electronic health records, my legislation will give mental health professionals access to comprehensive and up-to-date medical histories, enhancing the precision of diagnoses and reducing medication areas, Sen. Whitehouse said in a released statement on the bill. In addition, Lardiere, says that the Behavioral Health Information Technology Act of 2012 (H.R. 6043), introduced by Rep. Tim Murphy, is also intended to make behavioral health providers eligible for meaningful use. The bill would amend the definition of the term eligible professional, extending it to include behavioral and mental health professionals including licensed social workers, substance abuse professionals, psychiatric hospitals, community mental health centers, residential mental health treatment facilities, outpatient mental health treatment facilities, and substance abuse treatment centers.
4 Barriers to Overcome As many continue to push for the inclusion of behavioral health professionals for meaningful use incentives, it should be considered what can be expected as these professionals do ultimately adopt electronic systems. Though monetary incentives and technical support would help address some of the implementation barriers, there are other issues to be considered. One of those is the impact on workflow and the clinician/patient relationship. A study from the University of Florida has found that depression may go overlooked when physicians utilize EHRs. Patients who have three or more chronic medical conditions are half as likely to receive depression treatment in primary care practices that use electronic medical records as they are in practices that use paper-based records. While EHRs are thought to overall improve healthcare by providing better coordinate of care, the study raises question as to how computerized records could affect mental health care. While we don t know why electronic medical records are associated with lower odds of depression treatment in patients with multiple conditions, we think that either they reduce the amount of interaction between patients and physicians or they focus a physician s attention on physical health issues, pushing mental health issues off the radar screen, says lead investigator Jeffrey Harman, PhD, an associate professor and the Louis C. Jane Gapenski Team Professor of Health Services Administration at the UF College of Public Health and Health Professions. This research was also reproduced to look at treatment for anxiety disorders and had similar findings practices utilizing EHRs were more likely to overlook the anxiety disorder and focus on physical health. With depression we saw this effect in the more complex patients those that had three or more chronic conditions, explains Harman. But with anxiety disorders we saw the effect in everyone. So it demonstrates that there do seem to be some consistent negative effects of electronic medical records. Physicians need to be aware of this and not just rely on the electronic medical record to guide them through the entire patient visit. While Harman points out it s purely speculation not part of his study the assumption that physicians are spending more time looking at a screen than the patient is a potential explanation. Other literature has measured how much time the physician has spent looking at the patient versus looking at the computer screen and it seems to have an impact on workflow, says Harman. The physician might not be talking as much to the patient either. Though Harman s study looked at the primary care physician, some of these same workflow issues could come into play should more mental health providers implement EHRs. Social workers and other behavioral and mental health providers have an important patient relationship that s based on paying attention and recognizing the behavior of the person in the room with you, Richardson says. Very few social workers are adept at technology to begin with and when you have them start utilizing a computer system during their patient visit, it wouldn t be surprising to find it s a distraction. Until they re using systems more effectively, the workflow required may not be seamless. Fortunately, Richardson points out an upside in the fact that many social workers are already good note-takers and that s largely what EHRs are all about. The concept of concurrent documentation is not new to the social worker and that s really how EHRs work, Richardson says. So it s just a matter of learning the new system. Instead of
5 doing concurrent documentation with a pen and paper, they re doing it with an electronic system that may have drop-down tabs or places to type. In looking back at Harman s study, and the diagnosis of mental health problems at the primary care physician s office, the actual make-up of the software itself may also be a problem as it seems the prompts and guidelines within the system take more of a focus on physical health. The other issue is that the built-in functionality of the electronic medical record focuses more on physical health problems, Harman adds. I d like to see that electronic medical records take into account mental health as much as physical health as we know how important mental health conditions are. Looking Ahead While there are certainly barriers to overcome, the potential benefits of EHR implementation are also great. Lardiere says that the ability for population management is a great benefit. EHRs could be used to pull lists of all patients with a certain disorder that are or are not receiving managed care and then measure whose doing better, he says. Measuring and quantifying patient systmpoms so that they can be tracked and compared is something that the medical community is very good at. But in our own industry, we ve been poor at population management and using data to improve care. That could change with EHRs. The benefits of EHRs can be tremendous, adds Little. But it comes down to the training and implementation process. If everyone from front desk staff to the clinicians themselves are not trained properly, you won t get the full benefit of the system.
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