March/April 2016 Issue
Integrating Behavioral and Primary Care — Technology and Collaboration
Technology and cooperation between systems is reducing fragmentation and connecting behavioral and primary care to better treat the whole person.
Efforts to promote and establish the integration of behavioral and primary health services have been under way for quite some time, in an attempt to improve patient care. For people with complex health care needs, integrated care and treatment of the whole person leads to a higher quality of care and better health outcomes. But this type of care requires increased collaboration between team members, and robust health information technology (HIT) is needed to meet the demands associated with day-to-day operations.
"Health information technology is important for both primary and behavioral care when care is being provided within those domains individually. It becomes even more important when you're thinking about coordinating care across domain settings," says Dina Passman, LCDR, US Public Health Service, acting team lead of HIT for Substance Abuse and Mental Health Services Administration (SAMHSA).
Seamless Communication About Shared Patients
That ability to communicate efficiently about shared patients is key to successful service delivery. "The need for [HIT] that can exchange data in a timely and accurate way is huge," says Maribel Cifuentes, RN, BSN, senior program officer at the Colorado Health Foundation. "Integrated care relies on teams. To solidify and make that team-based approach work, you need to have the right technical infrastructure in place."
Tasks such as data collection and documentation, information retrieval, and information sharing are all needed to support client care and clinical activities. Passman explains that when providers are working out of different locations, it's essential to have the right HIT in place to support those tasks in order to track patients effectively and accurately determine their service needs. "It allows service providers working in two different settings to eliminate redundancy, such as duplicate test procedures," she says. "You can see what care has been given, in which setting, at what time, and the results of that care."
When the supporting technology for integrated care falls short, this goes beyond mere inconvenience; it has the potential to impact service delivery and compromise the quality of care that patients receive. And much of the technology is indeed falling short. "The technology needs to be more aligned with the new delivery models and integrated care," Cifuentes says, "so that the systems in use are able to adequately collect, use, and report on data that address the whole person."
Data Management vs. Data Repository
A system must have appropriate data entry features to ensure data get entered in a usable format. In the absence of a structured data entry format, users may resort to alternate documentation methods, such as scanning and uploading documents containing the relevant information. In the short term, this approach is less than ideal, as it typically requires additional staff time and effort and it disrupts the clinical workflow. In the long term, this approach is highly problematic since the data are rendered unusable; they can be viewed but not manipulated in any way.
In contrast, data that can be readily accessed and aggregated for further analysis contribute to an organization's evaluation and planning efforts. Cohen cites the role of aggregate data to support population health management and quality improvement efforts: "We should be using the data to inform our processes, and then making changes based on what the data tell us." She explains that access to data that look at the aggregate group served is valuable, as this allows an organization to "look within to see how you can change processes and services or how you can take a chance on trying something new based on what the data are telling you."
Intentionally Designed Software Solutions Needed
A software solution may be functional in a general sense but fail to reflect a particular organization's process. "A common complaint from practitioners in many different organizations," Cohen says, "is that the workflow of the electronic health record does not match the clinical workflow."
Cifuentes advises that HIT should be intentionally designed to reflect the realities of day-to-day service delivery, with increased involvement from social workers and clinicians in the design process. Information technology specialists and software vendors may be the experts in technology, she says, but they aren't necessarily equipped to determine "what's usable on the ground for the people doing the work. What's meaningful and usable in the eyes of a clinician may be something very different."
It may be possible to resolve usability issues later on through customizations, but such work is typically expensive and time-consuming. Cifuentes points out that many practices, especially smaller organizations and community health centers that work with underserved populations, have neither the financial resources nor the technical expertise within their internal team to make such an endeavor feasible. This makes it all the more important that the technologies in use be well designed with clinician input from the start.
Supporting the clinical workflow also requires that critical health information be easy to retrieve at the point of care. Otherwise, patients and/or clinicians may be asked to recall information about past screening results, scheduled tests, and treatment recommendations from memory. Not only can this lead to patients being required to provide the same information repeatedly but there's also a risk that the information will not be recalled accurately or completely (Cifuentes et al., 2015).
According to Cohen, the lack of easy data retrieval at the point of care is a common complaint, with users reporting that they need to perform onerous, multiclick sequences to get to the desired data within a patient's record. "It's important for clinicians to become more involved in the electronic health record creation process," Cohen says, whether through direct employment within the companies responsible for system development or through greater involvement in system testing during development.
Passman echoes this sentiment: "Provider input is critical in the successful development and deployment of [HIT]."
Sharing Sensitive Health Information
"There are misconceptions about privacy restrictions and a lack of understanding around what is allowed/disallowed under HIPAA," Cifuentes says, "which can have an adverse effect on information sharing between team members. It's important that team members don't hold back from sharing important patient data due to misconceptions about the HIPAA rules." She advises that teams can work in different ways so that patient information is shared as needed, while maintaining compliance with all of the relevant privacy laws. For patients to receive the care they need, it's essential that health care goals be explicitly identified and communicated clearly; a lack of information sharing among team members can directly impact and compromise patient care.
Protecting Patient Privacy
Cohen notes that the use of data segmentation is particularly valuable for the control over privacy that it offers, which in turn encourages patients to share their health information. "This is especially important in the context of mental health because of the stigma attached," she says, "as a patient might not want all service providers to know that they're accessing mental health services." She also points out the need for providers to have conversations with their patients to explain to them how this type of information sharing improves the level of care provided, and cites medication as an example: "Being able to share about medication use can help ensure there are no adverse medication interactions that arise because one provider wasn't aware of what another provider was prescribing."
Data segmentation holds promise for improved information sharing going forward, but this requires standardization and consistency among different technologies. To further develop data segmentation practices and protocols, SAMHSA and the Office of the National Coordinator for Health Information Technology launched the Data Segmentation for Privacy (DS4P) initiative in 2011, establishing basic standards for data segmentation. "We feel confident that DS4P is mature enough to support the private and secure sharing of sensitive data, be it HIV status, substance abuse information, or any other behavioral health data," Passman says.
Patient Consent Management
Patients log into an online portal where they can manage their consent options, sign consent forms electronically, and modify or revoke their consent at any time. They identify the providers they wish to share information with, the information they wish to share with each provider, and the information they don't want shared. When a patient's health information is later being exchanged between health care providers, it passes through C2S where the patient's consent directives are applied. This process allows providers to exchange relevant patient health information more quickly and easily, while remaining compliant with applicable privacy regulations.
The C2S application was deployed in a pilot project between SAMHSA and the health department of Prince George's County, MD. It remained in use following the pilot due to its many benefits. The department reported that the tool broke down communication and integration barriers which were leading to fragmented care coordination for patients, and that patients' use of C2S helped to relieve the tension between providers.
"We've seen success both with Consent2Share and with the deployment of another system that used the DS4P standards," says Passman, referencing an opioid treatment program (OTP) service continuity project. She adds that plans are under way to launch another OTP service continuity pilot incorporating DS4P standards in 2016.
Capobianco also sees direct access to one's health information as contributing to patient empowerment—one of the core principles of integrated care—by enabling patients to take a more active role in managing their care. Describing the Families First patient portal, she explains: "[It] allows clients to see many parts of their medical record including their allergies, insurance information, medication list, problem list/diagnoses, procedures, lab results, and more. We encourage our clients to be active participants in their care and consider them a member of their care team."
This type of around-the-clock health record access also provides patients with greater flexibility and more options for addressing their health needs. "A busy working mother," Capobianco explains, "can use the portal at her convenience, rather than waiting for the office to open and possibly being put on hold. Clients can request a refill, referral, or appointment at the times most convenient to them." Making it more convenient for patients to communicate and engage in this way contributes to the ongoing connection between patients and providers; this in turn promotes earlier intervention when problems are encountered (Mitchell & Begoray).
Technology Needs to Catch Up
In terms of policy, the need to integrate behavioral and primary health care is firmly established as a health care priority. Substantial progress has been made, and the increased focus on providing integrated care is already yielding improved health outcomes. But for these efforts to truly succeed, more progress is needed among the HIT used to support service delivery.
Cifuentes provides an apt description of the current state of affairs and the road that lies ahead: "We're undergoing an exciting era in health care where we really are recognizing the importance of decreasing and ultimately eliminating the fragmentation in health care service delivery. The will is absolutely there to provide integrated care services that address the needs of the whole person, but the technology needs to catch up with the progress that has been made in care delivery systems."
— Susan A. Knight works with organizations in the social services sector to help them get the most out of their client management software.
Mitchell, B. & Begoray, D. (2010). Electronic personal health records that promote self-management in chronic illness. The Online Journal of Issues in Nursing, 15(3).