Author: SOS Blog

OpenNotes Project: Where does mental health fit in?

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On Monday of this week, Seth asked me if I had a topic for my current blog. As I had none at hand, he pointed me to last week’s episode of the podcast/NPR show, Science Friday. Seth is a regular subscriber to this series and I listen when I find the time. That effort is always rewarded by fascinating discussions of current science issues. For the science professional, wanna-be-scientist or interested layperson, this show is a ready source of truly valuable information.

On Friday, July 30, 2010 the discussion topic was a medical records project called OpenNotes. With the advent of electronic medical records (EMRs) and patient portals into the medical records system, it is only reasonable to begin to consider the nature of the records that physicians keep on their patients. The OpenNotes project is an attempt to allow some 25,000 patients direct access to what 100 participating primary care physicians write in their notes after seeing them.

The project will study the experiences of both the physicians and patients, the impact on work flow of such note taking/sharing, the possible increase in communications between patient and physician, and the reactions of both sets of participants to their experiences. The details of the study are published in an Annals of Internal Medicine article, Open Notes: Doctors and Patients Signing On.

The Science Friday discussion included concerns about sharing sensitive information with the patient and the ability of the patient to understand and process the information included in the note. It has especially been argued that the mental health patient might be too fragile to be exposed to the psychotherapist’s or the psychiatrist’s true evaluation of their status as stated in the progress note.

On the other hand, Concurrent (Collaborative) Documentation has been touted by some community behavioral health specialists as an essential tool for increasing both quality and efficiency of client interactions while simultaneously increasing client buy-in to the treatment plan. The New York State Office of Mental Health writes:

It has been suggested that Concurrent Collaborative Progress Notes were the ‘way to go’. What about uninterrupted direct face to face contact as the best way to achieve high rates of engagement and retention in our clinics?

Concurrent documentation does not require the clinician to take notes during a session or to detach themselves from the recipient. Rather it is advised that at the end of the session, a brief review of the session takes place and the recipient and clinician collaboratively record the progress note. This process supports the delivery of person centered services and often provides the clinician with important feedback about the recipient’s perspective and information obtained from the session.

The process of creating this record concurrent with the meeting and collaboratively with the client is the epitome of an open record. While the OpenNotes project does not go quite this far, it certainly opens the door in this direction. Since the patient owns the record, it seems only fair that they should have easy access to that record and even participate in its creation.

My background as a Feminist Therapist has long given me a strong leaning in this direction. In the view of Feminist Therapy, the treating professional is a consultant having special expertise who is hired by the client to assist them in solving their “problem”. This is certainly also the case in the medical office. The physician has expertise the patient is seeking in their efforts to treat illness and to live healthier lives. This collaborative relationship is more a meeting of equals working together for the patient’s benefit than a dictation of treatment by an authority-figure intent on successful treatment and risk management.

What do you think about opening progress notes to your patients and consumers of service? How would that change the work done by the provider of services? How do you imagine it would change the experience of the consumer?

Please share your comments below.

Information Overload: TMI

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Almost two months passed between my post last week and the last one before that. The combination of family illnesses followed by vacation and recovery from travel put me in a position of being so far behind in the reading I usually do that I could not possibly catch up. My personal inclination was to duck my head and try to ignore the overwhelming sea of information.

I found myself strongly empathizing with practitioners, administrators, and behavioral health care personnel of all stripes who spend their days trying to provide quality mental health services to their patients…and then spend their nights worrying about what has occurred that day that might get in the way of or assist them in doing their job, but not having the time or the energy to pursue that information. Certainly, the information is readily available on the Internet, but who has time.

There have been numerous discussions of the effects of too much information (TMI) on our functioning. In July, 2008 Nicholas Carr wrote an article in The Atlantic called Is Google Making Us Stupid? This year he has written a book length exposition of that subject called The Shallows: What the Internet is Doing to Our Brain. His thesis is that our brains are literally being changed by the way the Internet is organized. He posits that jumping from one place to another by way of hyperlinks results in shallow pursuit of topics rather than the in-depth exploration of a subject allowed by books. In my brief exploration about his book, I found an extremely articulate review and commentary by Venkatesh Rao who mentioned and hyperlinked to the blog of Jason Kottke, a writer whose name I had heard but had never read. I have demonstrated for you an example of Carr’s thesis. I got distracted from obtaining support for my original thought by the way the Internet presents information and by the ease of pursuing that linked information.

Back to my original thought…here I am adding one more place where there is a bit more information for you to take a look at…or not. You might find this a convenient place to check for information about behavioral health care and its place in the world-at-large, or you might drop in occasionally just to see if there is anything that interests you.

For those of you checking in for something interesting, here are a couple of tidbits.

  1. ONC (Office of the National Coordinator for Health Information Technology) has published a final rule in which it establishes a temporary certification program for electronic health records as required under HITECH. As reported by Healthcare & Technology blog, this rule should allow progress toward approval of certifying organizations for EMR products.
  2. iHealthBeat reports on release of final rules for “Meaningful Use”. Many observers believe that the easing of requirements for the meaningful use of an electronic health record required to receive stimulus funds made available under HITECH will make it easier for eligible providers to receive funds. Other observers believe that even the easing of the standards will not make it simple for stimulus funds to be acquired, even for those who have already purchased and implemented EMRs.

It appears that life gets more complicated all the time, even if we have information. Since I do believe that knowledge is power, I will keep trying to pass some of what I come across on to you. Thanks for reading. Please let us know what you are thinking about. Just enter your comments below.

The Healthcare Experience….Firsthand

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Six weeks ago, I started writing this post. I think it is time to put finished to it.

The second half of May and first half of June were a challenging time for us. Two elderly parents had acute medical needs at the same time in different cities. Both were hospitalized, one in a critical care unit.

During this time I found myself thinking about different aspects of the experience. For those of you who have not yet had the responsibility to care for an elderly parent, these issues might be interesting to look forward to. For those of you who are our age-mates, you will probably have additional issues to offer.

  1. Medicare mostly works. (Medicare with a secondary insurance works even better.)
  2. Health care workers, for the most part, really seem to care.
  3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates.
  4. In the heat of the emotional moment, having siblings helps, even if they are in a different state.
  5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional.
  6. The toll on family caregivers is huge.

1. Medicare mostly works. Medicare with a secondary insurance works better. I know doctors complain about Medicare and the amount they are reimbursed and about dealing with Medicare claims. I also know that health care services are provided without question when Medicare is the payer. In an emergency situation, not having to be concerned about the method of payment allows everyone to focus on the care of the patient. I think there is a great deal to be valued in that.

2. Health care workers, for the most part, really seem to care. Health care workers are overworked and hospitals are understaffed. Nurses and nurse technicians are responsible for so much documentation that they often feel that direct patient care gets shortchanged. In two separate hospitals in two parts of Florida, my experience was that hospital staff did an excellent job in spite of the demands on them…and that they really cared about their patients and about the job they were doing for them.

3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates. Without a spouse and/or children or some other sort of advocate, people do not get as good care as when an advocate is present. The reasons are simple. A sick person is not in any position to ask for assistance, to question the treatment being provided, to assure the medication they have been handed is the correct one, or to guarantee that they understand the instructions they have been given.  If no one is present to say that they are hard of hearing, verbal instructions and questions may be forever lost. Even if a staff person eventually realizes they are not being heard, all of the previous interaction including important questions about history, may have been in vain. Without another person who understands how to go between the patient and the staff, a person may well get sicker because they could not ask for help or did not want to be a bother, could not question the protocols being followed and give benefit of their personal experience with previous treatment, did not recognize the medication they were given or understand the name and function of the medicine when the nurse administered it, or did not understand the follow-up instructions and the rationale for giving them.

4. In the heat of the emotional moment, having siblings helps, even if they are in a different state. Siblings are an asset when dealing with ill parents. Having others with whom to discuss the events and issues is crucial. They help generate additional questions that should be asked. They remind one another of family health history and events that can easily be forgotten. They can share the responsibility for sitting with and encouraging Mom or Dad. Having others to participate in important decisions if a parent is not capable of making those decisions for themselves is invaluable.

5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional. Rightfully, hospitals and health care workers do not want to make decisions for a patient. They especially do not want to make decisions that are inconsistent with the wishes of the patient. They will strongly and clearly recommend what they see to be the best course of care and, with the patient’s permission, they will implement those recommendations up to the limits that the patient sets. If the patient has no person or document setting the limits, all care will be provided as the staff recommends and all of the care they recommend will be provided. Being clear about the limits is only fair to one’s children and essential to one’s care providers.

6. The toll on family caregivers is huge. No matter the outcome of the health care incident, the emotional and physical cost to family caregivers cannot be underestimated, especially if the other elderly parent is one of those caregivers. We most often think about the sick person and how they handled the health care event. It is important that we also think about the family members who participated in the caregiving for Mom or Dad while they were in the hospital and during the caretaking that follows.

My quick Google search for “caregiving” yielded 2,270,000 results. “Family care giving for older adults” yielded 924,000 results. Obviously, this is an area in which interest has exploded. While many of the search results are for some sort of paid service, adding the word “free” at the end still resulted in 514,000 hits. Many communities offer respite care and support groups through their local hospice agencies. Online information and organizations abound. As we baby-boomers age, I fully expect that this will become an industry in itself, with paid and volunteer and not-for-profit organizations.

In the meantime, we are very glad that our elderly parents made it through this round with the health care system. I wonder what your experiences with elder care and our health system have been. Where do you see us heading and what role do you see for behavioral health care in this elder care world?

Please share you comments below.

Managed Care Organizations Oppose Parity

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An organization called the Coalition for Parity, Inc. comprised of managed behavioral health organizations (MBHOs) has filed suit to halt the implementation of the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act. This group has as some of its members Value Options, Magellan Health Services Inc., and Beacon Health Strategies Inc.

As reported by Open Minds and American Psychological Association Practice Organization, the lawsuit challenges the rulemaking process and has requested a temporary restraining order to stop the rulemaking process from moving forward. They argue that the Departments of Health and Human Services, Labor and Treasury overstepped their rulemaking authority in how they interpreted the statutory language and violated federal rulemaking procedure in publishing the rule as they did. While the judge denied the temporary restraining order because the law will not be enforced until July 1, 2010, the court will hear the case as presented by the parties to the action.

On May 9, 2010, the NY Times reported that insurance companies and employer groups are also objecting to the rules.

In a suit over the rules, Magellan and other companies said the concept of nonquantitative limits was “boundless and ill defined” and would reach virtually every policy and procedure used to manage mental health benefits.

As most mental health providers can readily attest, the procedures used by insurers and managed care organizations to limit costs and usage of behavioral health services have themselves been “boundless and ill defined”; after all, a treatment plan certainly could not be a valid treatment plan if it is printed on the wrong form. The MBHOs have been innovative in their development of “every policy and procedure used to manage mental health benefits.” Unfortunately, most of that management has consisted of denying or limiting the amount of service provided and placing onerous requirements on providers.

The NYTimes article states that:

One premise of the law is that mental illnesses often have a biological basis and can be treated as effectively as many physical ailments. But insurers say it is impossible to use the same techniques in managing the treatment of colon cancer and schizophrenia, or heart failure and major depression.

What do you think? Is it reasonable to assume that mental illness and addiction can be managed using the same techniques as are used to manage the treatment of cancer or heart disease?

Please share your comments below.

Patient Consent for Exchange of Information

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The HITECH section of the American Recovery and Reinvestment Act (ARRA) added privacy and security requirements that providers of health care services must follow in handling the Protected Health Information (PHI) of those they treat over and above those provided for in HIPAA. HIPAA allowed PHI to be exchanged for treatment and operations without patient consent as along as patients were so notified in the organization’s Statement of Privacy Practices.

HITECH provides for stronger controls. It requires that the provider be able to inform the patient (upon the patient’s request for the information) about all the times that PHI has been released by the organization (disclosures), to whom it was released, and the purpose of the release. This includes release of information for operations and billing. If you send claims to an insurance carrier via a clearinghouse, you would need to be able to document every time a claim was sent and that it went to both the clearinghouse and the insurance company. If you send it to the payer directly on their web site, you would still need to be able to document every time you did that.

HHS has been gathering comments from provider organizations about the burden this will place upon them. How the rules are ultimately written remains to be seen.

At the same time, the HealthIT Policy Committee has been working on a framework for privacy and security of PHI as we move toward EMRs and the electronic exchange of identifiable personal information. An attempt is being made to come up with methods and understandings that will allow a national standard and method of exchanging PHI in spite of different laws and requirements in each of the 50 states. A Privacy and Security white paper series explores these issues.

Part of the current concern is the point in an exchange at which a specific consent should be required from a patient for release of their information. It is believed that patients feel fairly secure when provider #1 releases information to provider #2 whether the provider is a lab or another physician. Trying to determine the point at which comfort in an exchange is lost and the requirement of consent is triggered is part of the challenge. For example, if provider #1 has consent to send information to provider #2 but the only method of doing so is through a third party (like a clearinghouse or directory), does additional consent need to be obtained for that transaction? What kind of situation must exist to trigger a patient’s right to “opt out” of the electronic transaction.

These are important issues that pertain to information electronically exchanged for billing and operations as well as for treatment. Avoiding the use of an EMR will not shield you from addressing these issues if you send claims electronically. . . even at a payer’s web site. 

What do you think about protecting the PHI of the consumer of services?  What are you doing to assure that you meet the requirements of the law? Please share your thoughts and comments below.