The number of folks able to validate “best practices” with significant research data is startling…meaning it ain’t many.
There are a ton of “best practices”, or different “brands” of therapy in use across the nation with no single method of proving on a grand scale how well they work. Maybe if they were tracked in an interoperable Electronic Health Record (EHR), and shared among professionals, a handful of these methods of treatment would have the data needed to prove their worth. The fact is, we’re behind the curve in this. Recently H Wesley Clarke, director of SAMHSA’s Center for Substance Abuse Treatment shared his feelings on the condition of Health Information Technology in the field at the 2011 National Conference on Addiction Disorders, and he’s convinced that the EHR is under-deployed, to say the least.
It’s all about data. Clarke understands that without analyzing the data that could be gathered using the EHR, professionals in addictions treatment are slow – as snails – to get the job done. In my experience, there are some professionals who believe documenting their treatment in the EHR slows them down and detracts from therapy. The question becomes, how do they know their brand of treatment, what they believe to be their “best practice” is the best way to help the consumer? Without documentation and a means to measure outcomes we’re relying on gut feeling, and when gut feelings are stood alongside outcomes measurement data, who knows whether they’ll be borne up unless we compare?
When a consumer paying for her own treatment (no insurance or Medicaid), she may want to know where her money’s going. She may respond better to the professional if there’s a study that can be quoted showing the effectiveness of the best practice she’s participating in. One thing I’ve learned after a number of years serving professionals with EHRs is that the more data you have, the more impressive the study. When I run across studies with absolutely huge data samples used to draw the conclusions, I’m inclined to believe the study’s true without even reading the study or book…call me trusting, but it’s trust based on data.
Assessments are the EHR‘s greatest tool to provide measurable outcomes…ask enough folks with substance abuse problems questions about suicide, and compare the results with people who lack the addiction disorder, and you start to see patterns. How do we know the measurement tool (the assessment) is worth its salt? Are we asking the consumer the right questions? Once we determine there is a danger of someone hurting themselves and we decide to treat it, how do we know that best practice used to treat that danger is the most effective treatment we can use?
Without data, we don’t know.
Without the EHR, our data can be insufficient. Without computer assistance, analyzing data just takes too long and is prone to mistakes in data compiling and analysis.
OK, so the EHR solves the local data problem in a professional practice, clinic or multi-location facility…When does it happen? There are a number of professionals who have used electronic documentation for a number of years, however the bulk of our field is in the dark…Email and Facebook on the work computer, and maybe Word documents about patients, which is a no-no when it comes to confidentially.
The EHR is the best tool going to help improve treatment. So, let’s get started, it will make H Wesley Clarke happy and is likely to save lives and help a bundle of consumers be happier, too.
That still leaves the question of how to get huge data samples an open issue. That requires interoperability and data sharing among professionals across the nation, and next time I’ll share some expert opinions (other than my own) on how to get that job done.Read more →
Perhaps the greatest service information technology can deliver to the mental health and addictions field goes substantially untapped.
I talked with a half-dozen of the largest social service/mental health/addiction treatment organizations in New York City recently, and felt unsurprised and somewhat saddened that a couple highly placed folks shared that their organization was just now getting around to setting up Electronic Health Records(EHRs) with integrated tools to measure outcomes of consumer treatment. One of the most important tools we have to measure treatment effectiveness is data, a resource that’s largely untapped. Treatment data feeds into that fabulous tool, the EHR, and the outcomes of different approaches can be measured. Effective treatment documentation is not just therapy session notes and how certain best-practices (motivational interviewing, REBT and other types of therapy) contribute to improvement of a consumer’s condition, but also blood, urine and saliva toxicology and breathalyzer results. Assessments have been administered for many years, and the outcomes of a large number of these tools have been ignored, simply because gathering and analyzing the data takes people with time to pour over paper-based records. These days, even EHR data is being ignored…but less and less as more viable data is gathered…it’s used to justify grant funding for a number of projects.
When a consumer comes to a professional, he can be desperate for help. Healthcare solutions, even for mental health and addictions treatment, gain attention and value by proving they work. Treatments can be proven effective and are more likely accepted by professionals into common usage when based on a lot of consumer results for treatment. Results gathered in an EHR tend to be more reliable because the samples can be bigger, from a number of locations, and data can be shared, contributing to outcomes studies on a grander scale. Plus, analyzing the results becomes a quicker process with computers doing the math. When a consumer is given a bi-weekly assessment, asked a bundle of questions about, say, how he feels as certain treatments progress, those check boxes the professional clicks on equate to changing the field for the better. One day, when the National Health Record is a reality, participants in treatment studies can include millions of de-identified consumer results nationwide. This will result in bringing more effective treatment to the field more quickly.
Sure, a few single agencies and perhaps a couple collaborations have been paying attention to this type of data; that’s how we know some treatment helps consumers with different diagnosis’ have better lives, and how the EHR can contribute to the effort. In a large part, however, as supported by the conversations I mentioned above, EHRs are either not on line at all or the companies are still implementing something that suits their need…or more interestingly, planning to build their own. Also interestingly, most software vendors include functionality like assessments, progress notes, treatment plans, scheduling modules and other commonly needed features, but the two items that get the most attention are the design tools and the reports used to develop this key functionality all over again so it’s different for each agency using the system.
What if there are better tools than what professionals are using now? How will they know without analyzing outcomes?
To the rescue comes NIATx, consultants like MindHealthBiz, and a host of other organizations providing education, advice and services to make sure one of the outcomes of the EHR is measurable outcomes data.
It’s all evolving now, and that makes for a continuation of the most exciting time ever in American healthcare.Read more →
Executive Summary New York State Medicaid Health Homes have been defined, including the offer of payment for providing the coordination of care among a network of providers required to be a Health Home. Providers are diligently completing applications (due November 1, 2011). Electronic communication to facilitate this coordination of care for Severely and Persistently Mentally Ill (SPMI) consumers is critical to deliver care in a reasonable amount of time. A prime goal for the Health Home is to reduce emergency room and hospital stays for these folks. This system of care is most efficiently managed with the help of interoperable software. An exploration of current thinking follows, discussing questions that have been raised in conjunction with efficient and effective planning to share data among Health Home network providers and the involvement of the Electronic Health Record (EHR) in this effort at the care provider level, and the involvement of the RHIO in securely sharing that patient data at the network level.
Although the EHR is not required to be in place at the outset of the Health Home adventure, some system of communication throughout the Health Home network is required. Without an electronic solution with a modicum of automation, documentation and communication requirements for coordinating treatment for some consumers will be onerous. The requirement of a plan to have an EHR in place within 18 months for all care provider organizations involved with Health Homes seems like a lot of time to some. It’s not; there are too many project details involved to delay. A few software companies brag that they can have an EHR up and running in 90 days. That is likely true, MindHealthBiz actually uses similar rapid change cycle software implementation methods. Care providers on the other hand may falter in meeting aggressive targets simply because they don’t have professionals with requisite skills and bandwidth available to do the job in a short time frame. Implementing an enterprise EHR is a huge task in itself, and tackling electronic communications among care providers for a SPMI patient complicates the job…this is a completely new application for software that has only the foundation elements defined and not yet assembled.
Paying for EHR Software As usual, the first question that arises is “who’s going to pay for all this?”
HEAL grants have been suggested as a way to pay for EHRs at the provider organization level, as significant work will need to be performed to get software ready to securely and electronically share patient data among members of a Health Home network. A number of HEAL awards have been granted over the past few years with regard to sharing consumer information among care providers, as well as establishing regional centers for Health Information Technology (HIT) assistance. The results of these grants are available to providers if they choose to use them.
Currently, Meaningful Use incentives are the best bet in gaining revenue to offset the expense of software. A few software companies capable of deploying to a large HHS organization have gained certifications required to qualify to receive Meaningful Use incentive funds. Other software companies are in the process of earning the certification, or plan to apply soon. If a care provider agency plans to fund their EHR purchase with Meaningful Use incentives, there are a few things to pay attention to from the outset. • Currently an organization must apply for incentives through their eligible professionals (prescribers, usually doctors) (http://blog.samhsa.gov/2011/09/09/behavioral-health-organizations-begin-receiving-incentive-payments-for-health-it/) o For Behavioral Health, The Behavioral Health Information Technology Act of 2011 (S. 539) is active in the US Senate to establish more appropriate criteria (http://www.informationweek.com/news/healthcare/EMR/229301263) for our field, and expand the list of eligible professionals to include other licensed professionals o The current reimbursement is $63,750 per eligible professional…if you have ten doctors working, that’s a significant amount to be paid over five years. If you don’t you’ll need the aforementioned bill to pass in order to collect significant incentives for Psychologists and Licensed Mental Health Counselors • Thirty percent of the eligible professionals’ consumers served must be Medicaid funded • Core Measures (http://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf) are generally attested to by the EHR vendor, however the agency is responsible to use the tool and meet the requirements.
There are more details (like connectivity to SHIN-NY (Statewide Health Information Network for New York) to address and more measures to meet as the EHR is used. If we address the foundation elements above first, future requirements are designed to fall into place as long as the provider uses the EHR as intended according to the certification and follows the rules. Of course a gap analysis performed by a neutral party is appropriate due diligence for any organization planning to be included in a Health Home network.
Recently I performed a survey of major New York City providers, like New York City’s HHC, and discovered that the majority of hospitals and large human services provider organizations have no enterprise Behavioral Health EHR on line, and are either just now implementing, or more likely, engaged in a purchasing process for the software.
This last point is a stickler, and where providers of care can stumble a bit in doing what they need to do to continue collecting Meaningful Use incentives. Some agencies have created a full time position for this job, others contract with companies like MindHealthBiz to assure they collect the incentives without incurring penalties along the way. Participants in the Meaningful Use incentive program are required to provide on-going proof of performance like self-attestation that will need to be proven in order to avoid having to return incentives already paid.
Connectivity Who is your Regional Health Information Organization (RHIO)? Are they working with your software vendor? Answer these questions and you’ve started a project, so be prepared to have adequate human resources available with time, persistence and expertise to dig into the details. It is best for care providers to have a voice in development of any system regarding what data flows to what electronic destination, and exactly how it gets there. Software vendors have varying levels of knowledge and expertise in confidentiality requirements and exact workflow within care providing organizations. Your organization could be a model for development of the Health Home network plan for your vendor, with great say in product development. Act quickly.
The point of electronic connectivity is communication throughout a disparate, multi-provider treatment team, through the Health Home’s care coordinator / case manager. Technology exists for the software vendor and RHIO can enable this, and it’s necessary for them to cooperate with one another on exactly how the electronic communications will flow among treatment team members. Questions arise at the care-giving level: How do I know my consumer has seen another provider? Who owns the treatment plan, and how is it shared? What notes can/must I share? The list of elements that affect care at the provider level continues.
As shared earlier, it’s important to be involved from the outset with your EHR vendor and have some say in the development of how new functionality will work. Would you rather your professional staff guide the details of gathering and sharing consumer data, or a software company’s project manager and programming staff? This has been a pet peeve of mine in software manufacture; programmers seldom analyze several common workflows for the same task in different care provider settings. One very handy remedy to this problem has turned out to be the dual edged sword of designer tools that come included with software packages.
These tools can potentially help save a ton of development costs. On the other hand, if a care providing agency doesn’t know the vendor’s communications plan for the Health Home network or doesn’t want to wait for a solution they may develop their own technology with design tools. This can hurt the provider as the vendor follows its development roadmap at their intended, albeit usually slow, pace. Be aware of details like this and avoid mistakes that waste resources and money.
Oh, one more connectivity item in this short story….Managed Care for all NYS Medicaid is the next step for our world, so remember to garner some sort of electronic link to your EHR with your Managed Care Organization (MCO) or BHO. This avenue may provide valuable encounter data and speed authorization processes. The BHOs to move forward with have been (or are being) defined in your region, and that may or may not mean the provider agency is destined for big change for managed care.
A comprehensive Release of Information must be negotiated to meet requirements of the Health Home, 42 CFR, the other provider agencies in the network and other interested parties. My suggestion has been an electronic form provided through the RHIO that includes all network member agencies. I would like the ability to disclose the sorts of information that will be shared among agencies and give the option to the consumer to select which agencies he approves with checkboxes, or “all Health Home network agencies. Some plans laid for this adventure include only the latter, not the option for a consumer to pick and choose. That said, the consumer’s choice may boil down to costs being covered by Medicaid…or not. More will be revealed as the details are ironed out and the technology is fine tuned.
Of course, if you’d rather not rush into an enterprise EHR purchase, your RHIO may have a software solution they would be happy to provide for a monthly fee; you’ll still need to implement it, and that effort is still expensive in money and the provider agency’s human resources. This software would be an “Application Service Provider” (ASP) arrangement, and may be adequate for the interim period while agencies select their EHR. Just make sure the ASP software is certified for all ARRA purposes and you can live with the functionality limitations.
Functionality The right way to go about understanding shortcomings of software technology is to balance requirements with the reality of who enters what data where. A functionality grid fills in the blanks that are opened by a gap analysis and returns a “score” for each vendor involved. These grids are used commonly in Requests for Proposal, and can be limited to functionality needed to accomplish the goals of a Health Home. Some of the Health-Home-specific elements that should be considered include: • A robust referral module o Drop-down dictionary selections for all Health Home Network members for multiple screens involved in a consumer’s treatment o Other network care provider treatment and discharge information should be tracked as it may affect your care’s outcomes for the consumer (psychotropic medications, physical trauma, etc) • A Health Home Requirements Checklist to assure the Health Home Case Manager/ care coordinator has information required to make reasonable consumer care decisions; all providers involved need to share their findings and cooperate with one another, so the best solution would be interactive among care providers • The care coordinator will need live access to key data for utilization and quality reports from all Home Health Network providers • Treatment data transfer mechanisms compatible with a number of EHRs o Note: A number of formats are already in place for HIPAA electronic formats as well as tools like the Health Level-7 (HL7) to securely share demographic, clinical and transaction data…your vendor may or may not elect to use these standard formats, replacing them instead with their own proprietary mechanism; certification issues may ensue if that’s the case • A pool of funds is promised to Home Health networks for proving effective treatment: o What is the mechanism to measure improvement? o What is the base line for the measurement? o How is the data aggregated? o Are these Quality Control measures reflected in tools in each care provider agency’s EHR? • Account for the 3M Clinical Risk Groups within the EHR and entry of that data into the consumer record during intake and sharing the score with the multiple treatment team members • Immediate access to Diagnosis & Treatment data from other agencies & possible storage of some of that data in the patient’s local record. • Active tracking of available Health Home slots with Health Home Network interaction • Some required functionality may not be available from some vendors, however, if they intend to stay in business, there is a roadmap to comply with the requirements; Be aware, there may be additional costs to care providers • It is wise to track whatever a consumer does, counseling sessions, physical health treatment, even if they simply show up for activities, track their presence and reason for being in the facility • Document Imaging attaches electronic files like scanned treatment documents and fax files from other agencies to your EHR’s consumer record…All agencies in the Health Home network are required to have an EHR 18 months after the start date – until then, some will have little or no technology and rely on telephone calls and faxes until that time, so other members will need to account for recording conversations and attaching such electronic documents to the consumer record in their software; not all EHRs come with document imaging, sometimes they can be quite expensive to add into the mix
In Closing The Health Home goal of coordinating care for SPMI consumers is lofty, and has been proven effective in New York. For care provider agencies participating in the Health Home program, the EHR is a requirement, and a lot of work and inter-provider cooperation is involved in bringing it up to speed. There’s time to do this, however, with a task like this, a dedicated human resource needs to be involved in order to meet the 18 month requirement for completion and the likely wish to take advantage of Meaningful Use incentives to help pay for the EHR.
One critical aspect in creating a functional electronic network for the Health Home environment to communicate and coordinate consumer care is the willingness for the RHIO to work with a number of software vendors. Vendors tend to work with differing platforms. Even though they all may be ODBC compliant, they way they actually work can present challenges to communication. The jealously-guarded code and database behind the graphics we see can be as different as night and day among software programs. The RHIO’s willingness to work with all comers in this is only half the equation. Vendors will need to be willing to cooperate with the RHIO, other software vendors, and multiple care providers to define and possibly accept foreign methods of accomplishing the Health Home electronic communication goals. Be as certain of upcoming costs as possible, and understand an exact dollar amount is not likely to be available until the project is complete.
All focused functionality needs to be in place as soon as possible. Since this involves development on multiple platforms, a comprehensive plan is needed. It’s certain that at least some RHIOs and software companies are working on this, to their individual or partnership advantage. Are your RHIO and EHR vendor working together, or at least have an agreement to work together on the same plan?
Contact MindHealthBiz at 631-419-6879 or firstname.lastname@example.org to discuss details of your situation and how your agency can influence the process to implement an effective, efficient EHR solution. Leverage the earned wisdom of an IT professional required to advance your project to participate an electronically integrated Health Home network.Read more →
Treating drug addiction with drugs is nothing new.
Disulfiram, more commonly known as Antabuse has been around to help folks stop drinking since the 1920s…it makes the abuser sick if they drink. Methadone has been used for opioid treatment since the mid-1960s. These days, medications like Naltrexone are used to treat both opioid and alcohol dependence. The word is these drugs take the edge off the craving, which can be a key motivator to relapse. A difficulty in the past has been in actually tracking the prescriptions and medical treatment associated with treatment. In the 1990’s I worked with Gus Johnson, who invented a low-cost, comprehensive software system that tracked methadone and other medication prescriptions and administration with a link to specific consumer records; everything from writing the doctor’s order to dispensing was handled by the software, automatically saving all treatment records. Since then, a few companies like Metha-Soft and SMART have been moderately successful, resulting in a number of specialty software programs that work just fine for these purposes. These software programs are very focused to the clinic environment, and may not seek certification required to participate in ARRA funding to pay for software upgrades.
Where are the affordable comprehensive Electronic Health Records (EHRs) for small agencies? It’s getting tough for a clinic to focus only on opioid treatment or just alcoholism, since clinics are becoming increasingly involved in associated behavioral health and physical health issues. Larger software companies with an enterprise approach to electronic documentation and workflow management are certainly available, some with associated addiction treatment functionality, while others may not see an advantage to developing all the special features required in addiction treatment. Playing in that ballpark usually involves developing a bundle of said development by the software company, plus screen design and reporting tools that come with the system. If that advantage isn’t available, professional organizations generally get stuck with a never-ending series of development fees. In either event, some skilled human being needs to get paid for the development (good news for MindHealthBiz, since that work is part of the business).
Enter the almighty dollar.
Today, addiction treatment for a high number of consumers is funded by Medicaid, and not as many, but some, by Medicare. As incentive to use the EHR, beginning in 2015, Medicare payments will start to decrease for treatment agencies not using a certified EHR in a meaningful way. Medicaid doesn’t seem to have the same across the board penalty, but Medicaid programs are in financial jeopardy. Medicaid payments may also be affected for consumers who also have Medicare coverage. The skeptic in me suspects the decreases pioneered by Medicare may follow in future Medicaid adjustments.
Decreasing funding makes it tougher still to pay for the software update required to deliver an effective EHR and billing engine to professionals with all the right functionality for outcomes tracking, billing, etc. All this functionality is great stuff that benefits the consumer, however it all costs money in one way or another.
The upshot of this discussion is that smaller agencies need certified Electronic Health Records in order to improve their technology and track prescribing of these new medications. Enterprise (software that handles all an agency’s data and reporting needs) EHR software vendors are in a rush to get certified, so they can quite simply stay in business. In order to do that, the software is required to have an electronic prescribing capability, along with the ability to share patient data with Regional Health Information Organizations, (RHIOs), Health Home networks (http://www.health.state.ny.us/health_care/medicaid/program/medicaid_health_homes/)and organizations providing or tracking care to consumers from multiple care providers. The kinks are currently being worked out regarding consumer confidentiality, and that will be successful, I have no doubt. Smaller, specialty software vendors like the companies mentioned above have quite a challenge ahead of them.Read more →