Along with more than 1,600 other behavioral healthcare professionals, I attended the National Council for Community Behavioral Healthcare Annual Training Conference in Orlando last year. Of the 95 exhibitors, about one-third were software vendors. Each was hoping to score a demonstration opportunity with a CEO or CFO who was window-shopping or, better yet, in the market for an electronic health record (EHR) application. Similar to past years' conference offerings, the EHR topic was holding its own last year against heavy-hitting topics such as evidence-based practices, integrated behavioral and primary healthcare, and risk management and staying out of jail (According to Andrew Quinn, a former federal prosecutor and plenary speaker, healthcare fraud is number two on the FBI's hit list after terrorism). So why are we in behavioral healthcare still in a holding pattern about EHR adoption?
The rationale for a wholesale move to EHRs (which should have happened yesterday) is indisputable: Effective management of the tsunami of documentation required by payers, licensors, and accrediting bodies is just the frosting. The cake is the capacity for systematic collection of data, which can inform us regarding client profiles, common problem areas, and promising treatments. With EHRs we ideally can engage more easily in treatment outcome measures, leading to evidence-based practices and significant cost savings. Choosing this course of action now ultimately will reduce the global burden of disease for future generations.
Coming back down to earth, to present and practical thoughts, the ease and dependability of data storage and transmission trump the musty smell of misfiled manila folders in damp basements and self-storage units (Those of us in the Northeast who lost paper records to last year's spring flooding know exactly what I am talking about). The ability to quickly access an archived record is critical when prompted by a client's return to treatment or, on those hopefully rare occasions, by an attorney's request or subpoena.
What Stops Us
So why can’t we get off the dime? I think the reasons are similar to those offered when behavioral healthcare folks are asked about treatment outcome measurement and evidence-based practices. They fall into four categories: cost, trust, autonomy, and fear of change.
Cost. There is no question that implementing and maintaining an EHR system require significant investment. The real question, though, is what is the cost to an agency of not knowing client population demographics, guessing at utilization rates, or falling short on information in grant applications.
Trust. Trust is a little more complicated. Those at all levels in the industry, from the monitors to the payers to the provider agencies to the clinicians and even consumers, ask how data are used, who sees the information, and “Will I be penalized if the results are less than stellar?” One consumer recently confided in me that he exaggerates his symptoms on the self-reported, computerized treatment outcome measurement survey his private insurance carrier requires. He found, through experience, that his therapy benefits were curtailed when he reported feeling better. So to be assured of continued coverage, he underreports (lies about) his improvements in treatment.
HIPAA regulations were designed to protect the privacy of personal health information electronically stored or transmitted, but consumers and others justifiably worry about breaches, especially with the increased ease of transmission. People, can we please remember not to put the client's name in the e-mail's subject line?
Autonomy. If trust is complicated, think about autonomy. Through EHRs standardization is not only possible, it is a primary goal and benefit. It is also a double-edged sword.
Imagine computer access for all providers throughout an agency or system of care, working in the office or the community. There is one client record into which any number of providers can enter information simultaneously and universally. Working within HIPAA guidelines, that information then can be accessed by any caregiver, any time of the day or night. With this capacity, coordinated and collaborative care is enhanced substantially. Standardization through EHRs allows for aggregation of data, which then can inform outcome measures, evidence-based practices, and areas needing improvement. However, depending on the interpretation, the notion of standardization can fly in the face of concepts such as the individualized treatment plan or patient-centered care. EHRs do provide easy access to clinical documentation in real time and over time, which allows clinical managers to hold practitioners accountable for their care and to measure whether clinicians are adhering to evidence-based or preferred practice protocols.
My sister recently made a midlife career change from being a baker and pastry artist to a licensed mental health counselor. When she bumped into the evidence-based practice controversy or “manualized treatment” as it was called, she mused, “So I went to school for six years and gave up a 30-year baking career so someone can hand me a cookbook?”