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May/June 2013 Issue

EHRs in Behavioral Health — A Digital Future?
By Lindsey Getz
Social Work Today
Vol. 13 No. 3 P. 24
Many behavioral health providers are excluded from meaningful use incentives, but that must change to allow comprehensive EHR implementation in mental health and substance abuse treatment systems.

In February 2009, President Obama signed into law a stimulus package that included more than 100 pages dealing directly with funding to stimulate the adoption of electronic health records (EHRs). Dubbed the Health Information Technology for Economic and Clinical Health (HITECH) Act, $19 billion was committed to advance HIT use through monetary incentives, with up to $44,000 available per eligible professional under Medicare and $63,750 per eligible professional under Medicaid, and potentially millions for eligible hospitals that could demonstrate meaningful use.

Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services Incentive Programs that govern EHR use and allow eligible providers and hospitals to earn incentive payments by meeting specific criteria. Driven by those incentives, many practices have adopted EHRs and discovered its benefits, including efficiency and improved quality of care.

That’s great news for hospitals and physicians, but behavioral health providers mostly were excluded from these incentives. While there is an initiative for change, as it currently stands, the HITECH Act does not extend those incentives to behavioral health providers.

Being Left Out
“Frankly, I was horrified that we were left off,” says Virna Little, PsyD, LCSW-R, SAP, senior vice president of psychosocial services and community affairs for The Institute for Family Health, headquartered in New York City. “The government is putting all this effort into integration and coordinated care and then has left half of the providers off the grid. Behavioral health providers are critical to patients’ overall care, and those records should be integrated into the electronic infrastructure.”

Currently, the only behavioral health providers eligible for meaningful use are psychiatrists and some nurse practitioners under the Medicaid program. Organizations that provide integrated health care (both physical and behavioral) also may have eligible physicians. But overall, behavioral health facilities are not eligible, and many practitioners say that means they will not be inclined to adopt EHRs despite the potential benefits to their practices and patients.

“I’ve been on both the medical side and the behavioral health side, and the fact is that the implementation process, steps, procedures, and planning are the same whether it’s medical or nonmedical,” says Michael Lardiere, LCSW, vice president of HIT and strategic development for the National Council for Community Behavioral Healthcare in Washington, DC. “We have the same support needs. There are huge workforce issues that arise with EHR implementation, and that’s also true whether it’s medical or nonmedical. But we not only don’t have access to monetary incentives, we also don’t have access to the support programs available to assist with implementation that medical providers have available, such as the regional extension centers.”

While behavioral health providers are in serious need of workflow analysis and redesign support during EHR adoption—same as the medical community—the specific issues that arise during implementation are different because the medical community operates in a different manner than behavioral health providers.

“Both medical and behavioral health providers need support, but the differences come in surrounding issues of workflow within the practice,” Lardiere says. “Workflow operations are just different in behavioral health care. Oftentimes, behavioral health providers offer many different levels of care—from outpatient to residential or training programs—and all of that needs to be taken into account. Also, when a patient goes to a medical practice, he or she is usually seen by an assistant, who stages the patient before the doctor even comes in, whereas with behavioral health you often see the clinician right away. Those workflow differences are important in terms of how the EHR is set up.”

Another key difference between medical and behavioral health involves confidentiality laws, which have the potential to be a major barrier to adoption. In fact, many are concerned that unless their questions over the privacy of mental health and substance abuse information are addressed, that portion of the medical record will never be fully integrated into an electronic network. “If you’re a substance abuse organization and you share information outside of your own organization, there are different confidentiality requirements that must be followed,” Lardiere says. “Currently, the health information exchanges are not technologically sophisticated enough to process those added requirements. It’s another example of medical EHRs not really being designed to fulfill the needs of the behavioral health community.”

Extending Incentives, Increasing Adoption
Of course, without incentives being extended to behavioral health providers, all of this may be moot, as adoption rates will remain at a minimum. “Without the meaningful use dollars available to behavioral health providers like social workers, there are just too many economic barriers for most practices to adopt these systems,” says Jeff Richardson, MSW, executive director of Mosaic Community Services, a nonprofit organization in the Baltimore metro area specializing in serving individuals and families with limited resources. “Most behavioral health providers are not working in large hospital systems with a lot of capital to roll this out. Purchasing the system, having the staff available to implement it, and updating the infrastructure are all very expensive endeavors. Most of the behavioral health community is already undercapitalized, and you need capital in order to even purchase the systems. We need the incentive of those meaningful use dollars.”

Richardson says there is so much involved during EHR implementation that he calls it a “near impossible task” to complete without help. “It’s not just purchasing the system, but all of the time and money involved in actually putting it into place is a massive undertaking,” he says. “Take an organization like mine where we have 700 employees but only 25 are eligible for meaningful use dollars. That’s a near impossible task.”

Little says that without sufficient funding, behavioral health practices will wind up with small-scale and ineffective systems that simply don’t meet their needs. “Practices not only need funding surrounding implementation but also technical assistance in selecting a system,” she says. “You don’t know what you don’t know, meaning many of these practices don’t even know what questions to ask when it comes to selecting a system. My advice is to seek out mental health providers who have been successful in implementing a system and find out everything they can.”

While most professionals assume that purchasing the EHR software is the biggest expense, Richardson says that’s really the least expensive part of adoption. “The software itself is the cheapest part of the process,” he says. “It’s being able to afford support along the way, in learning how to use it and training staff. The financing of these systems without broader resources available is a major challenge and really slowing the adoption of EHRs among behavioral health providers. And in terms of behavioral health as a profession, that puts us even further behind in the ‘bigger health care discussion’—an area where we’ve fought hard to be included.”

Big Benefits
Besides the benefit of being included in the overall health care discussion and aiding with the integration of medical and behavioral health, implementing EHRs offers other benefits to providers. Little personally is a huge fan of EHRs and has been using a system since 2002. “I feel like my ability to see the benefits of EHR utilization come from having worked with a comprehensive and sophisticated electronic system that has reporting and clinical functions all in one,” she says. “It’s incredible what you can do around care measures when you have a good system in place.”

The medical community already has found that, despite challenges, EHRs have great potential, including improved safety and quality of care, patient convenience, and better patient health outcomes. For medical practices that already have implemented EHRs and offer patient portals (online applications that allow patients to interact and communicate with their providers), patients appreciate being able to access their own medical records online. Patients of behavioral and mental health practices could see some of these same benefits, while an EHR system can help the overall practice run more effectively.

While the majority of behavioral health providers remain excluded from meaningful use incentives, there has been a legislative push toward policy that would add mental health providers to EHR incentives. A bill introduced by Sen. Sheldon Whitehouse (D-RI) would expand the Medicare and Medicaid EHR incentive programs to include mental health workers and facilities. This bill, the Behavioral Health Information Technology Act of 2011, seeks to ensure that HIT is available to behavioral health, mental health, and substance abuse treatment professionals and facilities. Whitehouse has said that “mental health care is a critical component of our health care safety net” and believes that allowing such providers to access the available incentives will improve patients’ overall care.

“By expanding the use of electronic health records, my legislation will give mental health professionals access to comprehensive and up-to-date medical histories, enhancing the precision of diagnoses and reducing medication areas,” Whitehouse said in a press release about the bill.

In addition, Lardiere says that the US House of Representatives version of the bill, the Behavioral Health Information Technology Act of 2012, introduced by Rep. Tim Murphy (R-PA), is intended to make behavioral health providers eligible for meaningful use. The bill would amend the definition of the term “eligible professional,” extending it to include behavioral health professionals and facilities.

Barriers to Overcome
Beyond the push for their inclusion in meaningful use incentives, considerations should be made for what steps are necessary for behavioral health providers to adopt electronic systems. Though monetary incentives and technical support would help address some implementation barriers, there are other issues to be considered, such as the impact on workflow and the clinician/patient relationship.

A study from the University of Florida found that depression may be overlooked when physicians utilize EHRs. In this study, patients who had three or more chronic medical conditions were one-half as likely to receive depression treatment in primary care practices that used EHRs as they were in practices that used paper-based records.

While EHRs may improve overall health care by providing better care coordination, the study raises question as to how computerized records could affect mental health care. “While we don’t know why electronic medical records are associated with lower odds of depression treatment in patients with multiple conditions, we think that either they reduce the amount of interaction between patients and physicians or they focus a physician’s attention on physical health issues, pushing mental health issues off the radar screen,” says lead investigator Jeffrey Harman, PhD, an associate professor and the Louis C. and Jane Gapenski Term professor of health services administration at the University of Florida College of Public Health and Health Professions.

The research was reproduced to also look at treatment for anxiety disorders, with a similar result: Practices utilizing EHRs were more likely to overlook the anxiety disorder and focus on physical health. “With depression, we saw this effect in the more complex patients—those that had three or more chronic conditions,” Harman explains. “But with anxiety disorders, we saw the effect in everyone, so there do seem to be some consistent negative effects of electronic medical records. Physicians need to be aware of this and not just rely on the electronic medical record to guide them through the entire patient visit.”

While Harman acknowledges that it’s speculation and not part of his study, the assumption that physicians are spending more time looking at a screen than the patient is a potential explanation for these results. Other literature has measured how much time physicians have spent looking at the patient vs. looking at the computer screen, and it seems to have an impact on workflow, Harman says. Additionally, the physician may not be talking as much to the patient either.

Diagnosing mental health conditions at a primary care physician’s office may be more challenging because EHR software prompts and guidelines focus on physical health. “The other issue is that the built-in functionality of the electronic medical record focuses more on physical health problems,” Harman adds. “I’d like to see that electronic medical records take into account mental health as much as physical health, as we know how important mental health conditions are.”

Though Harman’s study examined primary care physicians, similar workflow issues could come into play should more behavioral health providers implement EHRs. “Social workers and other behavioral health providers have an important patient relationship that’s based on paying attention and recognizing the behavior of the person in the room with you,” Richardson says. “Few social workers are adept at technology to begin with, and when you have them start utilizing a computer system during their patient visit, it wouldn’t be surprising to find it’s a distraction. Until they’re using systems more effectively, the workflow required may not be seamless.”

Fortunately, Richardson points out an upside in the fact that many social workers already are good note-takers, and that’s largely what EHRs are all about. “The concept of concurrent documentation is not new to the social worker, and that’s really how EHRs work,” he says. “So it’s just a matter of learning the new system. Instead of doing concurrent documentation with a pen and paper, they’re doing it with an electronic system that may have drop-down tabs or places to type.”

Looking Ahead
While there certainly are barriers to overcome, the potential benefits of EHR implementation also are great. For instance, Lardiere says the ability for population management is a great benefit. “EHRs could be used to pull lists of all patients with a certain disorder that are or are not receiving managed care and then measure who is doing better,” he says. “Measuring and quantifying patient symptoms so that they can be tracked and compared is something that the medical community is very good at. But in our own industry, we’ve been poor at population management and using data to improve care. That could change with EHRs.”

“The benefits of EHRs can be tremendous,” Little adds, “but it comes down to the training and implementation process. If everyone from front desk staff to the clinicians themselves are not trained properly, you won’t get the full benefit of the system.”

— Lindsey Getz is a freelance writer based in Royersford, PA, and a frequent contributor to Social Work Today.