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.
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:
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 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.”
It’s a way to systemize the permission to exchange patient information rather than deal with it on a patient-by-patient, situation-by-situation basis, says Clark. “If you’re going to have an integrated structure, whether it’s co-located or a partnership, you need to have thought it through and have incentives going back and forth—‘we’ll send our patients to you, you’re the entity that sees our patients on a regular basis.’” Clark says that this sets up the qualified service agreement where each side respects the confidentiality of the information, “and you essentially at that point have unlimited access to that information.”
SAMHSA has issued 49 supplemental grants to behavioral health providers for funding health IT infrastructure “with the expectation that they facilitate interoperability with the general health providers in their community,” but providing first the basic affordability of health IT, Clark says. “You can’t have interoperability, you can’t have bi-directional flow of information if one partner in that dynamic has access to computers ... and the other partner in that system has paper and pen.”
The bigger problem facing the behavioral health community, says Clark, is that as a market, it’s dwarfed by the physical healthcare sector and only peripherally eligible for the billions of dollars in federal stimulus funds for Meaningful Use of EHRs that IT vendors are racing to facilitate. “Although people talk about privacy and confidentiality as barriers, the fact is there is a larger impediment, which is a resource and technological [adoption] impediment.”
Evolution to payment model alternatives like the patient-centered medical home may provide the financial motivation to put EHRs in behavioral health hands, says Leipold, who is executive vice president and chief operating officer of the Valley Hope Association, an addiction treatment firm with centers in seven states. Valley Hope also is a vendor of an internally developed EHR. Health reform carries “the clear requirement that everybody will have to function in this structure of the electronic health record,” he says. “If you don’t, there’s going to come a time in the future where you cannot participate in reimbursement strategies.”
A key challenge now and a bigger one in the medical home model is medication reconciliation, says Morrison. So far, Capital Region has isolated within River Bend the contingent of providers who treat patients with medications, putting them on the EHR for the hospital and medical group, but in a separate database. For starters, that provides more power to manage the medication component of behavioral health, since the medical EHR has tools not included in the more assessment-based behavioral version.
“Ultimately we’re going to have to figure out how to integrate the meds so that the drug interaction checking can occur on one coordinated list of meds rather than having someone in the middle try to figure out if this is a problem or not,” he says. As motivation, the healthcare network need only refer to its own research on the healthcare needs and costs of its service area. With a database of records on most people in the region, Capital Region looked at the 5 percent who use the most resources—emergency department, hospitalizations, visits—and found that nearly 70 percent of that fraction have a co-morbid mental health condition.
Integrating behavioral and physical health management doesn’t always have to be expensive or complicated. At Capital Region Health Care, a simple device placed in patient homes to collect data each day and encourage compliance with care regimens had a positive impact on behavioral health.
Among the components of the healthcare network is a regional visiting nurse association responsible for monitoring people’s recovery after hospital stays and preventing relapses and readmissions. Using devices called Health Buddies, patients key in personal data that are tracked by nurses, who can dispatch someone quickly if a problem arises.
“The economic model for the VNA was that if they get paid a bundled fee to take care of patients, they wouldn’t have to make as many phone ‘visits,’ they would make visits to people who actually needed intervention,” says Deane Morrison, the network’s CIO.
Another partner in the network, the mental health services group, wondered if the devices also could improve compliance for their own lagging patients. In a 100-person trial, 50 used the devices and 50 did not. Halfway through, the 50 devices were switched to the other cohort. Compliance went up by 15 to 20 percent when mental health patients entered whether they took their medications, says Morrison.
But that wasn’t all. Participants also being treated for a medical condition entered whether they took the medications for that condition. Even though it was a secondary question, outcomes of co-morbid health conditions also improved—for example, a 20- to 30-percent improvement in management of blood sugar. “We didn’t even try to do that, but people started managing their diabetes better,” Morrison says.
That’s something to tuck away for the day when providers are accountable for the high costs of treating people with co-morbid physical and behavioral conditions. “With a little bit of prodding through the Health Buddy, we not only got people to take their meds more regularly but we got them to pay attention to their other conditions and improve the way they were managing all their conditions,” says Morrison. “That is a very positive sign for taking care of this group of patients.”
John Morrissey is a Chicago-based healthcare writer.