New IOM Report: Best care at lower cost

In early September, the Institute of Medicine published its most recent report on the state of healthcare in the U.S. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, identifies three major “imperatives for change: the rising complexity of modern health care, unsustainable cost increases, and outcomes below the system’s potential. You can download a free, prepublication .pdf version of this 450 page report before it is out in print.

The committee explored in detail some of the pressing needs of the system. They are convinced that we must move toward a healthcare system that learns from itself as rapidly as possible or the system is likely to self-destruct. We must learn how to incorporate research results more quickly, we must learn to change delivery systems that cost too much, we must move the system closer to its highest potential. In short, we must develop a culture of “continuous improvement to produce the best care at lower cost.”

FierceHealthFinance focused on the reported waste of $750 Billion a year (about 30% of the cost of healthcare in the U.S.) as one of the most important things to change. While that number is appalling, the fact that the figure reported was from 2009 is the most striking thing about it to me. Our system has become so complex that it takes three years before we know what it costs. We are constantly behind the curve, and must find ways to speed up the process of information assessment, dissemination, and implementation for change.

The behavioral healthcare system is often far behind the curve in implementing change that might be more productive. The public health and public behavioral health systems are deep in conversation and pilot programs related to integrating physical and behavioral healthcare. Suzanne Bennett Johnson, Ph.D., current President of the American Psychological Association (APA) identified the need to increase psychology’s role in integrated care as a primary thrust of her presidency; her presidential address also focused on this issue. I wonder how many mental health providers in the private sector are even willing to consider what changes to their work such an integrated system might bring.

Take a look at the very brief summary of the IOM report to see if you would like to read the whole thing. What do you think we need to do in behavioral healthcare to begin to address some of these issues?

Electronic Permanence: Changing records and releases

On September 22, 2011, I attended a webinar sponsored by the Business Operations for Behavioral Health Collaborative, a SAMHSA-funded joint venture of the National Council for Community Behavioral Healthcare, the National Association of Community Health Centers, NIATx, and the State Associations of Addictions Services (SAAS). The topic of the webinar was Health Information Exchange and Behavioral Health.

This is an area that has interested and concerned me for quite a while. As developers of software for behavioral health providers, SOS has for years been monitoring developments in the arena of Health Information Exchange (HIE). This is the method by which Electronic Medical Record (EMR) software will exchange information among providers and healthcare organizations. The HIE is both the process of exchanging information and any repository of that information for easy access by those with rights to the data.

This is the bugaboo that has always bothered me as well as my colleagues in the behavioral health software trade association to which we belong (Software and Technology Vendors Association). SATVA members are committed to assuring that our products share information only as the law allows and as consumers wish.

Work is currently in progress to assure that a universal method of acquiring patient permission for release of their information is part of any HIE. Such a method would undoubtedly allow a patient to specify providers to whom their treatment and diagnosis information can be released and any providers to whom it cannot be released. But what happens when a patient changes their mind?

Here’s a hypothetical example that jumps into the future by a few years, when all or most healthcare providers have EMRs and are connected into their regional HIEs.

John D. is admitted to the Emergency Room of a local hospital after a panic attack that he interprets as a heart attack. Among the papers that he signs is a release for the ER to access any information in the regional HIE about his health conditions. Since he is not thinking very clearly as he is sure he is dying from a heart attack, he signs everything put in front of him. After he is medicated, stabilized and sent home, he wonders about what he signed and which of his health information will now be available to whom. Does he really want his optometrist to know that he was treated with an anti-anxiety medication and prescribed an antidepressant (which he decided not to take)? Is it necessary for his urologist to have this information? What does he do to protect just that ER visit information and keep it from being sent on to other providers?

And what do our mental health and substance abuse patients do to secure their sensitive information?

This process concerns me because of my experience that once a piece of information has been entered into some large electronic database, getting it out may be near to impossible. Several years ago, I attended a conference in New Jersey. I rented a car, drove to the city in which the conference was held, returned the car and paid my bill in a timely fashion, and returned home.

The next time I needed to rent a car was three months after Katrina flooded New Orleans when my mother and I returned to check on her home and attend the funeral of one of my uncles. For some reason, the car was reserved in my mother’s name…the airline tickets were purchased with her card…even though I had placed my name on everything. The rental agency manager noticed something wrong when we picked up the car; there was a block on my account even though there was no balance. She overrode the block, gave me the keys to the car, and we were on our way. I did not give it another thought.

In several return visits to New Orleans, I again rented cars from the same company and always wound up with a car, not even knowing there continued to be a block on my account. Each time the agent or manager overrode the hold and gave me the keys. In November 2010, we arrived in New Orleans on a Sunday. The agent and assistant manager decided they did not have the authority to override the block on my account and there was no one they could contact to clear it. They refused to rent a car to me and offered no solution. They gave me a phone number I could call on Monday, but did not even offer my 90 year old mother and me transportation to another agency. I cursed and swore I would never rent from their unprofessional agency again and called my brother to come pick us up. Fortunately, he was thinking clearly enough to suggest that we go across the highway to a different company and rent a car there.

I did call the company the next day and eventually got the written apology and clearance of my account that I requested. It took six years for this correction of an error to happen.

What processes will we insist be put in place to assure that patients can change their minds about release of information or correct errors or enter corrected information into their records? What kind of advocacy will be required? What do mental health and substance abuse providers need to do to assure that the privacy of their patients’ sensitive information will be handled as they choose?

Please share your thoughts about HIE and EMRs and where we are going with this process.

Clinical Decision Support: Is Watson up to it?

Are you a Jeopardy fan? If you are, I am sure you know that in January of 2011, IBM’s supercomputer, Watson beat two of Jeopardy’s all time money winners, Brad Rutter and Ken Jennings. Watson is an Artificial Intelligence that can understand questions posed to it in natural ‘human’ language.

WellPoint, a BlueCross collaboration, is the largest provider of health benefits in the country. Their plan is to utilize Watson to sift through their patient databases to make diagnosis and treatment recommendations to WellPoint physicians.

This idea is not at all far-fetched and certainly a reasonable way for IBM to make some money off their huge research and development investment in Watson. They have also purchased some other companies that position them well for movement into the medical sphere.

Over the last four years, IBM has spent more than $7.8 billion to acquire database analytics specialists Cognos and SPSS, both formerly public, as well as data warehouse company Netezza, along with other private companies. In the first half of 2011, IBM spending on research and development exceeded $3.15 billion.
—International Business Times, 9/19/2011

What WellPoint is proposing to do is a starting point for a task all EMR’s will ultimately need access to and participation in. In order to meet the requirements for ARRA stimulus funds, eligible providers will need to utilize their EMR’s to help them make clinical decisions.

Clinical Decision Support (CDS) is a process whereby the physician gets notices and alerts from their software to assist them in making clinical choices that are based on data and evidence rather than memory and intuition. The Centers for Disease Control and Prevention (CDC) hopes to see public health organizations utilizing population data and statistics to guide their choices. They believe this will be one of the most impactful effects EMRs can offer the public health. The Office of the National Coordinator for Healthcare IT (ONC) wants to see individual physicians using Clinical Decision Support to advise their patients. Clearly, WellPoint plans for this level of intervention: physicians will have access to the data Watson can provide to assist them in making diagnoses and recommending treatments.

We talked in this blog about some of the potential benefits of CDS back in 2009. Since then, research on the benefits of supported clinical decision making has continued. A Google Scholar search of ‘decision support emr’ results in 16,800 hits. There have also been noted some shortcomings, most notably a phenomenon called ‘alert fatigue‘, wherein a provider gets so many alerts and notices that they stop attending to them or turn them off altogether. Obviously, we have lots to learn about how to present information to healthcare providers so they can use it most effectively for the benefit of their patients. WellPoint has decided to dive right in!

What do you think about being diagnosed by a computer? Will it be more effective or less so? What is the relevance of CDS for behavioral health?

Please share your thoughts below.


PHRs, EMRs, Data Security and Other News

Last week I asked you if you were using a Personal Health Record (PHR). I got only one response…from a college friend who is a technical writer. John is involved with a PHR company called medkaz. This company believes that all electronic medical records should be driven by and owned by the patient. Accordingly, they have developed a thumb-drive based product that the consumer will carry around with them. It is fully encrypted, so the privacy of the patient is guaranteed.

I believe the idea is that the patient will bring their personal record with them when they visit a doctor. The doctor can download relevant information of the patient’s choosing into their own electronic medical record (EMR) system. At the end of the visit with the patient, they will upload their note onto the patient’s thumb drive. The doctor can subscribe to this system themselves, but even if they do not, they will be able to use the patient’s information. This is one way to make sure that the people treating you have the most current medical information about you.

Over the course of the last few weeks, the reason for concern about what information health systems have and how they manage it again came into the public light. The Stanford Hospital in Palo Alto, CA reported that 20,000 records of emergency room patients had been revealed online by their collection agency…one of their Business Associates. The information had been posted on a web site for just short of one year. One of the affected patients saw the posting of the information and reported it to Stanford Hospital and Clinics.

According to IDExperts, there is good reason for concern about the security of medical data. The street value for a stolen medical identity is $50. Using that information, a Medicare or Medicaid or other insurance fraudster can file claims for services never provided….and often get paid.

In other news this week, the White House has proclaimed September 11-16, 2011 to be National Health Information Technology Week. The purpose of the proclamation is to call attention to and educate the citizenry of the benefits of and need for Health IT that will protect the privacy of the patient and involve patients in their health care.

Finally, the Office of the National Coordinator for Health Information Technology (ONC) has announced their new website,, designed to become the leading national resource on health IT for both consumers and health care professionals. The goal of the site appears to be to encourage personal responsibility for one’s health and health care through wise use of technology and coordinated efforts with one’s providers.

It was a busy week! Is there news you would like to share?


Psychologists and EMR: Movement forward

Last week I attended a continuing education workshop for psychologists at my local chapter of the Florida Psychological Association. Psychological Records: Basic Requirements and the (Forced?) Choice of EMRs was presented by Robert J. Porter, Ph.D., president of the Tampa Bay chapter and treasurer of Florida Psychological Association. Dr. Porter’s presentation was attended by about 30 psychologists and other mental health providers. The last FPA workshop on EMRs that I attended was over 10 years ago, and it was given by me. There were about five psychologists present at that workshop.

The difference in attendance speaks to multiple issues. First, Dr. Porter is an excellent presenter who talked broadly about EMRs. His years as a researcher and university professor combined with recent years in private practice give him great credibility. Secondly, the EMR landscape has changed hugely in the past decade with government requirements to migrate patient records to an EMR a distinct possibility.

The psychologists who are my age peers who used an EMR  loved computers and liked doing all their work there. Most of our age-mates would never have considered keeping records that could not be locked up in a file cabinet behind their locked office door. The younger psychologists who are now replacing us in the private practice community are not only willing to consider keeping their records electronically. . . they are willing to keep them online using a Software as a Service (SaaS) type product. The move from needing to hold the patient record in my hot little hands to allowing it to float out there in the cloud is a sea change.

While Dr. Porter presented a great deal of information in the two hours he spoke, there were several items I thought you might find interesting.

  1. The American Psychological Association published Record Keeping Guidelines in the December 2007 issue of the American Psychologist. If you are a psychologist and you keep records, you should read them. If you keep behavioral health records but are not a psychologist, you might take a look at them. Such Guidelines frequently become part of the standard of care in a professional community.
  2. The APA Guidelines recommend disclosure to the patient of your record keeping procedures, including the limitations of confidentiality of the records. Those limitations of confidentiality lead to a likely need to maintain a separate  record of care for each person you treat, including for each individual member of a family or couple. (Guideline 4)
  3. Ofer Zur, Ph.D., a licensed psychologist in California, offers extensive information about and continuing education on record keeping and many other aspects of behavioral health practice. [Retrieved 4/19/2011 from]
  4. Dr. Zur points out that a treatment plan usually includes problems or symptoms, a diagnosis, goals of treatment, interventions to be used to achieve the goals, and the rationale for use of those interventions.


I would add a quick note about the possibility of a requirement to keep records of psychological care in an EMR. At present, the only behavioral health providers who are Eligible Providers (EP) for ARRA funding to purchase an EMR are psychiatrists and nurse practitioners. Psychologists, social workers, mental health counselors and addiction professionals do not qualify, nor do psychiatric hospitals. While this may change, there is currenly no way for most mental health providers to obtain stimulus funds. At the same time, there is no requirement for them to move to an EMR, nor will they be penalized for not doing so (psychiatrists and nurse practitioners may be subjected to Medicare withholds). Fortunately, most of the products aimed at the private mental health practitioner are relatively inexpensive and can easily be obtained without resorting to government funding or a second mortgage on your house.

While an electronic medical record can be a powerful way to significantly increase the quality of the records maintained by you and your organization, you must know what you are required to maintain in the record. . . by the governmental jurisdictions and the professional guidelines to which you are subject.

How does your organization determine what goes in the client’s record? Who is responsible for those records? Are you using an EMR, a paper record, or some hybrid system?

Please share your thoughts on records in the Comments below.