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New technology, old questions

February 20, 2012
by By John Morrissey
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Any effort to “carve in” behavioral health records faces big hurdles
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As former chief information officer of a Maryland hospital system, Douglas Abel remembers the relatively brief consideration of behavioral health data in fledgling attempts to build a comprehensive information sharing network in the mid-2000s. Brief, because mental health and substance abuse information were pointedly “carved out” out of the process, says Abel.

The discussion, which was reprised years later when Maryland began designing statewide health information exchange, came to this conclusion: “It was an easier path to carve those [categories of data] out and set those aside, because that’s where you were going to generate the most conflict in trying to get all stakeholders to agree that sensitive information, number one, should be shared, and number two, could be protected appropriately,” says Abel, formerly with Anne Arundel Health System in Annapolis and, since mid-2011, an executive vice president at Netsmart Technologies.

At Capital Region Health Care—a New Hampshire healthcare holding company with a hospital, physician group and mental health practice—leaders made concerted efforts to integrate behavioral health into medical environments. It included placing practitioners from its River Bend Mental Health Associates into the hospital’s emergency department and at medical practice locations. But the information systems for behavioral and medical clinicians remain separate for now, says Deane Morrison, the Concord-based system’s chief information officer.

Physical, behavioral conditions are linked, but records are not

The aims of the federal government and commercial insurers to make providers accountable for health outcomes add financial consequence to statistics showing that behavioral health problems complicate medical health, and that people with co-occurring physical and mental conditions are the most expensive to treat and constitute an outsize share of healthcare costs.

But a coordinated and complete understanding of what behavioral and medical providers are doing for a patient requires coordinated and complete information sharing. Experts in both fields agree that while this is technically achievable, it won’t happen without determined effort on four fronts:

  • Clarification of federal and state confidentiality regulations that govern the protection and disclosure of a range of sensitive health information, such as individual alcohol and drug abuse treatment records.
  • Management of those protections within electronic health records (EHRs) and health information exchanges (HIEs) using common, software-based algorithms. 
  • Technological ability to exchange information from separate IT systems.
  • Affordability of health information systems in the behavioral health sector.

The recognition that people were coming to Anne Arundel with both physical and behavioral health conditions led the system to establish a substance abuse treatment facility, says Abel. But “as we were deploying a systemwide EHR, we immediately put the appropriate checks and security around the information about patients that were being seen in the substance abuse area.” That information was accessible only to clinicians who worked in that unit.

The River Bend group at Capital Region has its own EHR, but it’s completely separate from the hospital and medical practice systems, says Morrison. Behavioral health providers have access to their EHR from within the hospital and also can get access at a medical group location if a patient is treated at that location. With state privacy laws even stricter than federal, Morrison says it’s a challenge “that has to be thoughtfully worked through: How do you share mental health information appropriately with primary care and with the ED?”

Capital Region has worked around the problem by “essentially having the providers in the same space; fundamentally when they’re taking care of patients, they’re talking about the issues rather than being in two separate locations,” he explains. So the solution is not integration of the information but integration of the providers using it. “That seems pretty rudimentary, but believe it or not, that makes a big difference in coordinating care for our mental health patients.”

Technology offers solutions for handling privacy questions

Technology standards for sharing information are improving rapidly and no longer are the barrier they once were, says John Leipold, chair of the Software and Technology Vendors’ Association (SATVA), a trade group for vendors of behavioral health IT systems. Patient confidentiality remains a sticking point, though members of SATVA are developing an electronic system for managing consent-directive queries. “Privacy and confidentiality are the 800-pound gorilla in the room of otherwise wonderfully evolving healthcare standards, all of which are going to make medical and behavioral healthcare work better,” Leipold says.

The privacy laws are put there for good reason, he adds. The disclosure statute from the 1970s known as 42 CFR Part 2, for example, is “absolutely what we need” to keep people with addiction problems secure in seeking treatment without clues to their condition getting out via, say, the medications they’re taking.

But there are ways to enable behavioral/medical information sharing contractually among closely cooperating entities, says Westley Clark, MD, director of SAMHSA’s Center for Substance Abuse Treatment and strategic lead for the federal agency’s information technology initiative. “It is our belief that if you’re a substance abuse program, you can create what’s called a qualified service organization agreement with a primary care setting and exchange information that is useful for the care of the patient.”