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August 1, 2006
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Behavioral healthcare has unique needs for EHRs

The Certification Commission for Healthcare Information Technology (CCHIT) has just begun the process of reviewing electronic health record (EHR) software products for ambulatory healthcare to determine if they meet preset standards that include content, function, and interoperability. If a software product meets the standards, CCHIT will “certify” it (The standards can be viewed at http://www.cchit.org). But do these standards meet the needs of behavioral health service providers and practitioners?

On its surface, certification sounds wonderful because it holds the promise of being able to reduce the risk in purchasing software. However, certification is meaningful only if the standards are pertinent for the product, fully developed, and correct. Representatives of physical health systems currently have the strongest voice in EHR standards development, although behavioral healthcare, via SAMHSA and other entities, is now more fully involved.

It is my opinion that behavioral health is a specialty requiring many unique EHR standards. While a significant overlap exists between physical health's and behavioral health's data needs (e.g., similar demographic items and reasons for presenting for care), there are also areas in which data requirements and clinically focused functionality needs are markedly different. In addition, behavioral health rules and regulations can be quite different from those for physical health, adding variation to system needs.

The arguments for unique behavioral health EHR standards are complex and not at all clear-cut. For example, is the work flow of seeing a consumer, documenting that visit, and billing for the visit really so different in behavioral health settings than in physical health settings? Whether the service occurs in a school, residential setting, or office, isn't it really the same work flow? While I do see many similarities, the EHR systems issues are vastly different. Physical health software systems (partially because they must contain links to radiology, lab, pharmacy, computerized physician order entry, and other ancillary systems) are often larger (i.e., more labor intensive to manage) and more expensive than those that traditionally have served the behavioral health market.

Some of the differences that I think lead to the need for separate EHR standards include:

  • Behavioral healthcare service delivery often is required to directly include consumer involvement, including documentation that consumers have been involved.

  • Behavioral healthcare providers often are required to write strengths-based and recovery–focused treatment plans for each episode of care.

  • In many states substance abuse services have more stringent privacy rules, even pertaining to the sharing of information with mental health providers. Therefore, systems must have security and privacy functions that keep certain clinicians from accessing information about a consumer's substance abuse care.

  • In general, behavioral healthcare has more funding sources and oversight entities than physical healthcare (including child welfare, justice, and county agencies), meaning increased reporting complexity. A small provider entity might be required to send information to a state or local entity each time a consumer registers for care, as well as follow the primary payer's requirements. This means that the provider's software system must be able to send updates to records as information changes. In some states providers first send demographic and diagnostic information before learning which services the consumer is eligible to receive. This is virtually unheard of in physical healthcare.

  • Many behavioral health services occur in nontraditional settings, and many services are provided by nontraditional providers (including peer providers, unlicensed providers, and lay providers).

The software that many behavioral health agencies currently use already takes these factors into account. Thus, decision makers working on EHR standards should ensure that these factors are considered so that no provider must make his/her work flow fit the system, rather than have the system fit his/her work flow.

It is crucial to remember that software and its standards are simply tools to meet the promise of system improvement through widespread implementation of health information technology. We don't want the tools telling us what we must be doing; we want the tools to help us do better what we already do very well.

Sharon Hicks, MSW, MBA, is President and CEO of Askesis Development Group.