March/April 2016 Issue

Integrating Behavioral and Primary Care — Technology and Collaboration
By Susan A. Knight
Social Work Today
Vol. 16 No. 2 P. 20

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
HIT plays a central role in the delivery of integrated care by supporting communication and care coordination among all of the care providers. "When individual electronic health records are truly being used in a meaningful way, care providers are able to communicate seamlessly about any shared patients," says Deborah Cohen, MSW, PhD, a research associate and lecturer in the School of Social Work at the University of Texas at Austin.

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
The ability to extract data from a system for analysis and reporting purposes is just as important as a system's data collection capabilities. Otherwise, health care practitioners may be in possession of large volumes of patient data but limited in their ability to draw meaningful conclusions from it. "You need to be able to manipulate and act on the data," Cifuentes says, "in order to measure outcome achievement and guide quality improvement efforts. Otherwise, the system just becomes a 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
It's not unusual for health care practitioners to encounter difficulties when dealing with the constraints of their software solution. Integrated care exacerbates these difficulties due to the increased demands on the system. For instance, there is a need for features that support integrated teams working from shared care plans. There is also a requirement for reporting tools that can track patients with medical and behavioral health comorbidities over time and across care settings.

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
Whether a practice uses a single data management system or multiple systems, integrated care presents challenges to information sharing between team members. This is especially true in the case of sensitive health information, which includes areas such as mental health counseling, substance use treatment, and HIV status. This type of information is often subject to additional privacy protections beyond the standard protections afforded by HIPAA. Federal and state laws regarding disclosure of sensitive health information can leave health care providers in a difficult position when it comes to information sharing.

"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
In recent years, data segmentation has garnered attention as an effective method for protecting patient privacy while facilitating health information sharing between behavioral and primary health care providers. Data segmentation allows a patient to grant consent for specific sections of their health record to be shared without consenting to share the entire contents of their record. Sensitive data can be electronically tagged or segregated, readily distinguishable from other, less sensitive information.

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
The DS4P standards were used to develop Consent2Share (C2S), an open-source application that supports enhanced patient consent management. It helps to resolve the challenges and barriers that so often arise in integrated health care around the sharing of sensitive information, as it allows patients receiving behavioral health care treatment to authorize the sharing of sensitive health information between their health care providers.

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.

Patient Self-Management
Many of the HITs currently in use allow patients to access their health information directly, in the form of a personal health record. Personal health records have been identified as a strategy to make health care more patient centered and as a tool to promote patient self-management (Mitchell & Begoray, 2010). This is especially relevant in the context of integrated care, where better self-management practices are associated with reduced health risks and better health. "Knowledge is power, and improved knowledge of one's health hopefully leads to improved health outcomes" says Jill Capobianco, RN, MSN, director of Patient Centered Medical Home at Families First Health and Support Center in Portsmouth, NH.

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
Even though data segmentation, health record access, and patient portals are all playing a major role in supporting integrated care, many of the data management systems in use are still lacking in performance. There is a need for systems that provide better workflow support, easier data retrieval at the point of care, and more robust tools for advanced data analysis and reporting. Greater system interoperability is also needed for situations where behavioral health data and primary health data are collected in separate systems. When systems can't "speak" to each other or share information easily, this can lead to duplicate and erroneous data entry, as well as duplication in the services being provided.

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.

References
Cifuentes, M., Davis, M., Fernald, D., Gunn, R., Dickinson, P., & Cohen, D. (2015). Electronic health record challenges, workarounds, and solutions observed in practices integrating behavioral health and primary care. Journal of American Board of Family Medicine, 28:S63-S72.

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).