Tag: Behavioral health EHR

Case Management with Email Messaging

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Many of our customers include Case Management as part of the mix of services provided to clients. Among the seriously mentally ill (SMI) population, Case Management has become an essential service helping individuals gain the most from the services they receive. Helping the client take their medication as prescribed, assessing their current symptom status, intervening to alter treatment rapidly if a crisis is looming are all functions that Case Managers provide. These services are provided both in-person and by telephone.

A new study published in The Journal of General Internal Medicine suggests that email contact with a trained psychiatric nurse can dramatically improve the outcome of medication treatment for depression by internal medicine practices. Reported in Healthcare IT News on March 17, the study was a follow-up to a similar study using telephone contact with patients who had newly been started on antidepressant medication. According to the report, the email messaging was even more effective than a telephone call in improving the benefit of the medication.

The study utilized 208 members of Group Health, a consumer-governed, nonprofit, integrated healthcare organization that coordinates care and coverage for 600,000 individuals in Washington state and Idaho. The Group Health Research Institute (GHRI) was the responsible research organization. GHRI  is a non-proprietary, public-domain research institution within Group Health.

The Group Health plan includes a patient portal that has access into the organization’s electronic health record. According to the abstract of the article, the Intervention consisted of:

 Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record.

This study was motivated by poor improvement outcomes reported nationally for depressed individuals treated by their primary care providers with antidepressant medication. The goal of the entire research project is to determine if use of an organized plan of treatment including evidence-based follow-up services would result in greater effectiveness of medical therapy.

A significant movement is developing within the U.S. to improve outcomes of our healthcare system by providing services in non-traditional ways. The Connected Healthmovement seeks to improve healthcare services and outcomes by use of technology to remotely monitor and provide services. Partners Healthcare Center for Connected Health has been a pioneer in this effort. Their web site states the goal in this fashion:

Changing Healthcare Delivery

We are engaging patients, providers and the connected health community to deliver quality care outside of traditional medical settings. Telehealth, remote care and disease management initiatives reflect the opportunities for technology-enabled care programs.

What potentials do you see for the use of electronic methodologies like secure email communication with clients within your organization? Are you already engaged in such endeavors? What do you see as the obstacles to such care? What are the potential benefits to your clients? How do we get from here to there?

Please share your experiences, concerns and other comments below.

Your Health Information: Where do you want it?

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My extreme concern about data protection and privacy have made me wonder how effective the drive to electronic medical records (EMRs) will be, particularly in the behavioral health arena. My clearest recollections from the first day of my psychology internship at a community mental health center are all of the instructions related to protecting patient privacy. As a mental health software vendor, I have continued to have this strong drive to protect the data of any patient. Finally, HIPAA and HITECH have caught up with the concerns of those of us trained to put patient privacy protection ahead of most other concerns.

The rush to EMRs that can share information with one another (interoperability) has as its goal diminished costs and increased quality of health care. The need to keep that information secure and private is usually dealt with almost as a side issue. I have often heard statements like these: “Why, of course the data will be protected. Why are you so worried about keeping data private? Sharing it with other providers is much more important than privacy. Some compromises will need to be made . . . ”

The American Medical Association, in their discussion of patient confidentiality, briefly indicate their concerns about EMRs.

Electronic health information systems allow increased access and tranmission [sic] to health data.  Physicians in integrated delivery systems or networks now have access to the confidential information of all the patients within their system or network. Confidential information also is disseminated through clinical repositories and shared databases. Sharing this information allows patients to be treated more efficiently and safely. The challenge for physicians is to utilize this technology, while honoring and respecting patient confidentiality.

Sharing confidential information among treating professionals is only one aspect of this issue. Now we must consider to the issue of sharing the electronic data with the patient.  

According to John Fully on nextgov, patients want access to the information stored in the electronic records about them maintained by their physicians. 93% of patients have rarely or never asked their physicians for electronic copies of their data, but 70% say it is very important to them that doctors and hospitals provide those electronic records. 60% of patients and over half of physicians say sharing information from EMRs with patients will be a crucial measure of how successful health care reform and provision of stimulus dollars has been.

One potential method for sharing those electronic records is the Personal Health Record (PHR). After all, having an electronic copy of the physician’s record but having no way to store or to access it will not be a very beneficial state. As a result, provider organizations, payers, and even Medicare have begun to connect EMRs, claim histories, and PHRs as an effective way of tracking your health.

Even so, patients are hesitant.

. . . while the products use some of the same technology that banks use to secure financial data, some patients remain wary of putting health information online. Only about 4% of the online population uses Internet-based PHRs, according to Elizabeth W. Boehm, a principal analyst at Forrester Research Inc. in Cambridge, Mass. Many people don’t see the need, Ms. Boehm says, while others are nervous about putting confidential health information online.

That figure is telling. It is not that only 4% of patients use a PHR . . . only 4% of the online pupulation uses one . . . only 4% of the people who use the Internet all the time utilize an online PHR.

I have registered for the PHR used by my insurer. The Privacy policy says all the right things. I have entered some information into it, but I am still hesitant to put everything there. The conventional wisdom is that these programs are secure. I’ll give you an example of why I am slow to completely adopt.

About 18 months ago, I noticed that one of my mother’s physician claims was rejected by her Medicare supplemental plan. When I looked at the EOB more carefully, I noticed that it had been filed on my insurance plan rather than on my mother’s Medicare supplement plan. Since we both have the same insurer, I telephoned, explained what had obviously happened and was assured that it would be corrected. When I checked my PHR today prior to writing this blog, I found that claim still sitting in my record.

I have never been a patient of the physician who filed the claim, so I know he did not file the claim with my insurance information. I am thirty years younger than my mother and my first name does not come close to hers. But the same last name and address resulted in this confusion that has not yet been corrected. I cannot help but wonder what other two bits of information might result in the confusion of something important in my file and that of some stranger. Since this payer automatically adds claim information to the PHR, their system now sees me as the patient of a cardiologist . . . something I have not yet become. I wonder what other data confusions I have in store.

What is your take on PHRs? How do you see them affecting the behavioral health community? Please enter your comments below.

HITECH Act, Psychotherapy Notes and Test Results

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I am sure some of you remember that the HITECH portion of the stimulus bill (ARRA) included attempts to strengthen the protection of psychotherapy notes in the new Electronic Medical Records (EMRs). In fact, the Secretary of HHS was instructed by Congress to study whether the protections for psychotherapy notes granted by HIPAA should be extended to psychological testing.

HHS is finally gearing up to begin this study and the Substance Abuse Mental Health Services Administration (SAMHSA) has been tasked with organizing and conducting the study.

September 7, 2010
 
 The Substance Abuse Mental Health Services Administration (SAMHSA) is conducting a Confidentiality and Privacy Issues Related to Psychological Testing Data study, in close cooperation with the Office for Civil Rights (OCR) pursuant to section 13424 of the Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act (ARRA) (P.L. 111-5). This study is addressing whether the HIPAA Privacy Rule’s special protections relating to the use and disclosure of psychotherapy notes should also be applied to “test data that is related to direct responses, scores, items, forms, protocols, manuals or other materials that are part of a mental health evaluation.”
 
As part of this study, SAMHSA is hosting public meetings to bring together professionals in the areas of mental health and privacy protection to discuss current practices and the policy implications surrounding this very important issue. The next regional public meeting will be held at the U.S. Department of Health and Human Services Region 5 office in Chicago, Illinois, on October 7, 2010. The details of this meeting, as well as the project staff contact information, are contained in the embedded brochure…. 

 

Some of the issues that will be addressed are included on page two of the brochure.

  • What  activities  and  information  are  considered  the  “test  data”  that  is  part  of  a  mental health evaluation?  What are the relevant distinctions among test materials, raw data, and reports  or  assessments  with  respect  to  the  level  of  protection  currently  afforded  and/or otherwise necessary?
  • Are  there  circumstances  under  which  test  data  should  be  disclosed  to  third  parties?  Should  the  individual’s  authorization  be  required  prior  to  such  a  disclosure?  To  whom should test data be released?
  • How  would  affording  mental  health  test  data  a  higher  level  of  protection  affect  the workflow  in  medical,  behavioral  health,  or  psychological  practices?  Are  there  any additional  implications  with  respect  to  clinical  integration  efforts  and  the  increasing
    availability of mental health services in general health care settings?

Another regional meeting is planned for Los Angeles in November or December. SAMHSA does not indicate whether others will be held. This is certainly an important opportunity to have your voice heard if you are a practitioner whose primary work is psychological testing, if you are a consumer of services who might want or not want raw test data to be shared among treating professionals without your specific authorization, or if you are a potential recipient of such data.

Is the protection of psychotherapy notes and psychological test data an issue for your practice or organization? What guidelines do you currently follow in determining how such data are released? How would new rules affect you?

Please share your comments below.

EMR Certification Picture Gets Enlarged

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On March 2, the Office of the National Coordinator for Health Information Technology (ONC) announced a plan to approve organizations to certify electronic health record software programs. ModernHealthcare.com reported the announcement of this new plan by ONC head, Dr. David Blumenthal, at the big meeting of the Health Information Management Systems Society (HIMSS) occurring in Atlanta this week. The rule being developed will create a system for temporary testing and approval of products that meet the ARRA “meaningful use” criteria as well as a permanent structure for such certification. This is a process for certifying the certifiers.

Since the passage of ARRA last year, there has been rampant speculation about whether the Certification Commission for Health Information Technology (CCHIT) would be the only certifying body approved by HHS. Many who have felt that CCHIT is too closely tied to the large players in the medical EMR community have believed that diversification in the certification community should be a given.

Currently, CCHIT is the only organization designed to certify EMRs. Prior to ARRA, the certification was to a particular set of standards, features and functionalities decided upon by CCHIT as necessary for any electronic medical record program to call itself a player. In the past few months, CCHIT has added an ARRA certification to meet the requirements of “meaningful use” so that providers could qualify for ARRA funds. Unfortunately, the “meaningful use” definition is not yet finalized…and the cost of the ARRA certification is significant.

This cost of certification by CCHIT has been the primary concern for small software vendors. Those of us who have limited financial resources and small development staff have been worried that the fees and methodology of CCHIT would prevent us from obtaining certification for our products. Dr. David Kibbe, senior advisor to the American Academy of Family Physicians Center for Health IT is one of the critics. As reported by Neil Versel at FierceEMR, Dr. Kibbe believes that the cost and complicated nature of the CCHIT certification method stifles innovation and the development of new technologies.

This announcement by ONC may well open the playing field significantly. Whether the stimulus funds are worth the cost to achieve “meaningful use” is a separate issue that eligible providers will need to determine for themselves. Since these incentives are largely aimed at primary care providers, not many behavioral health organizations are likely to be impacted or even eligible for funds. But we must assume that the move toward EMRs in the general medical world will increase the pressure upon behavioral health providers to follow suit.

Behavioral Health EMR Systems Learn to Cooperate: A sneak peek at interoperability

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I am on my way back from two and a half days in Phoenix where approximately 40 SATVA (Software and Technology Vendor Association) member representatives, EMR users, and industry IT experts met to find a way for behavioral healthcare providers to exchange patient information using the electronic Continuity of Care Document (CCD). The CCD is the mechanism specified by current healthcare IT initiatives for the communication of critical patient information between providers. Ideally a care provider could rapidly get up to speed on a patient’s status by requesting and receiving a CCD from another care provider already familiar with the patient.

I first heard the term “continuity of care” in a healthcare seminar I took back in graduate school in the early ‘70s. It was an obvious, common sense concept that patients could receive better care at lower cost if providers were able to continue care already started by another provider, rather than starting over, duplicating care already rendered by the previous provider. Continuity of care requires that meaningful, usable information pass from provider to provider. Almost 30 years later, every patient in the US is familiar with the challenges of getting even simple demographic data, much less meaningful health records, transferred from one doctor to another. Well, the CCD might just be a solution to that problem.

Our meeting started with a demonstration of the creation of a CCD by the system of one SATVA member, and the display and subsequent import of that CCD by the system of another SATVA member. These are the exact capabilities that are mandated by 45 CFR, Part 170, HHS’s recently published Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology (Interim Final Rule).

Required or not, systems that are actually doing CCD interchange today are few and far between. To our knowledge, there are NO behavioral health EMR systems that do. Nevertheless, the technical proof of concept was convincingly demonstrated at our meeting — a valid CCD was created, and the generic medical information contained therein was displayed and “consumed” by another system.

In many respects, the technology is the easy part. The challenge that faced our group was to define a standardized way that behavioral health providers can represent their unique domain information within the CCD to allow accurate import by a receiving system. Think, for example, of the five-axis DSM diagnosis — something that exists only in our family of behavioral/mental health specialties. Ultimately, the DSM five axis profile turned out to be the focus of our group’s efforts.

The standard CCD contains sections for identifying information (technically called the Header section), Problems, Procedures, Family History, Social History, Payers, Advance Directives, Alerts, Medications, Immunizations, Medical Equipment, Vital Signs, Results, Encounters, Functional Status, and Plan of Care. A given CCD can contain one or more of these sections, in any order. In this context, the Problems section is normally intended to contain a list of diagnoses, but it is flexible enough to include other information including findings and observations, which means that “problems” in the behavioral health sense could be included when necessary to convey significant information that diagnosis alone could not.

One of the most important aspects of the CCD and related electronic documents is that they must rigidly adhere to standardized sets of coded descriptions that are included in the specification of these documents. For example, when diagnosis codes and descriptions are included in the Problems section, they must be either ICD-9 (until supplanted by ICD-10) or, better, the more universally used SNOMED-CT. The latter includes everything in the ICD, plus a great deal more, and is preferred. Before you get too worried, all the vendors present agreed that it would not be difficult to modify our products to take the sting out of SNOMED for you. Likewise, in Medications, drugs should be listed with their RxNorm codes, and in Results, labs should include LOINC codes. The use of these specific coding systems avoids ambiguity that could potentially result in misunderstandings and serious harm to patients.

The CCD is rendered in XML, a cousin of the HTML code that sits behind the content and presentation of the typical web page. As a result, the CCD can be displayed by any modern web browser. Without getting too technical, the CCD uses a related style sheet that determines the way the CCD data is displayed on screen. As a result, any CCD that you receive can easily be formatted to display in any way you like! Let’s say that you want the Alerts section (which contains important information such as allergies, adverse drug reactions, and perhaps such information as dangerousness) displayed in a bold red font in the top right corner of the page. You can modify your organization’s CCD style sheet to make it so. Thereafter, EVERY CCD you display will have the desired information in the desired font and position. It doesn’t matter who sends it. Compare that to searching through several inches of paper records that bear no resemblance to anything you do in your own organization. See what a breakthrough this would be? Below is the very same CCD, but displayed with two different style sheets. The fancier one is courtesy of Brett Marquard of Alschuler Associates, LLC.

Returning to the meeting, after considerable discussion the group determined that we could, in fact, communicate our beloved DSM axes within the existing CCD specification, with no need for extension or new templates (another component of the document specification). This conclusion was nothing short of huge! The fact that we can get what we need without having to go hat-in-hand to the standards bodies to plead for inclusion of something new means that implementation can go forward on a much faster schedule. Our goal now is much more modest – just an Implementation Guide that describes how and where to put our unique stuff.

If you are still with me, and are curious, we determined that Axes I, II, and III diagnoses will go into Problems, along with additional specific diagnostic criteria (as findings or observations) when necessary. Axis IV will go into Social History, and Axis V will, of course, go into Functional Status.

This initial core group of stakeholders expects to add supporters over the coming months, complete a well-tuned CCD Implementation Guide for Behavioral Healthcare Providers, and put it into use in the field. In the meantime we will move forward, with the expectation of obtaining official adoption by the relevant standards bodies.