One critical change regarding behavioral health is the growing recognition that, “once people get over the stigma, they see how interrelated behavioral health is with physical health. That's part of a growing trend that recognizes, ‘we need to heal individuals, not diagnostic codes,’ and to do that, we need to look at both the behavioral health and physical health factors in an individual's condition.”
Future health reforms target two issues: prevention and cost reduction. He believes an integrated deliver model can achieve both, provided that primary care physicians, in particular, are able to screen better.” He cites greater detection of depression and other behavioral health conditions as one key to improving care and reducing costs.
From an IT standpoint, Ganesan sees three methods of integration: total or “seamless” integration, which is the goal; and partial integration that would involve co-locating a primary care provider within a behavioral healthcare setting or a behavioral health provider within a primary care setting.
But once some level of integration takes place, substantial differences in workflow and business processes are likely to emerge. He cites three examples:
Intensity of care: Compared to primary care, where care frequency may be as little as once in every year or two, he notes that “behavioral health care generally requires a very high degree of intensity,” with weekly or bi-weekly visits not at all uncommon. So, IT systems must be able to cope with this difference in schedule intensity and complexity.
Documentation: Care documentation, too, is widely different. “There is far less quantitative data in behavioral health as well as many more way to measure outcomes relative to primary care medicine,” he explains, adding that “there is a need to integrate the various measurement tools from both disciplines” into evolving EHR, documentation, and billing systems.
Language/terminology: Finally, he notes, there's a great difference in the “language” used between the two specialties, citing the most obvious-the term patients versus consumers or clients.
These and other differences put constructive pressure on IT developers to think and design with greater flexibility, says Ganesan. And, their efforts to be more “flexible” are being aided by two externally-imposed requirements. The first it the EHR certification process that is mandated by the Office of the National Coordinator for Health information Technology to support users pursuing “meaningful use” incentives after the adoption of EHR systems.
“Certification is really helping the integration effort. “What it is doing is requiring that we bring in features from the physical health world. It makes everyone in the behavioral health IT field a partner in bringing that to our customers.”
Another step toward integration, the HHS requirement that all providers submit billings that use the larger and more complex ICD-10 system of medical billing codes by October 1, 2013, is just as important, though somewhat less settled among behavioral health IT developers at the present time, Ganesan explains.
Currently, it's typical for behavioral health clinical personnel to use DSM-4 diagnoses in their clinical treatment work and leave the “translation” of these codes into corresponding ICD-9 billing codes to administrative and billing personnel. These personnel often rely on small EHR or billing database lookup tables, offered by IT providers, that cross-match DSM-4 and ICD-9 codes.
The future of this relatively simple cross-matching function is somewhat cloudy, says Ganesan, since the new ICD-10 medical codes “are far more detailed and granular” than ICD-9 and the path toward integrating them with the also-new and expanded DSM-5 diagnostic manual isn't yet clear.
Noting that ICD-10 offers a system of behavioral health diagnosis codes, he asks, “Are we going to somehow marry the two or is behavioral health going to adopt ICD-10 outright?”
For providers, this is a legitimate question. But IT developers won't be able to choose, or at least not until their customers do: “We'll have to be prepared to support both scenarios,” Ganesan says, adding that time to decide is limited.
“There is no option. We have to embrace [ICD-10] one way or another and a simple lookup [similar to the ICD-9/DSM-4 lookup] will no longer be possible, since so much more information is required for DSM-10 codes.”
Ganesan adds that data security and access for an integrated provider group will also pose challenges. “If you have a primary care doctor working in your facility-does he or she need to have access to an individual's mental health records? That has to be worked out-that's a big issue.”
For help with issues beyond certification and interoperability, SATVA is looking to HRSA for help and advice. “We're looking to HRSA for input on the features that software providers will need to be building over the next five years.”
Ganesan maintains that “once you get past certification and interoperability-integration becomes much less a technical or IT issue and much more a business and workflow issue.”
He cites the recording of vital signs, the scheduling of dual appointments (primary care and behavioral health visits) and the evolution toward adoption of ICD-10 codes as examples.