Tag: Mental Health EHR

Psychologists and EMR: Movement forward

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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 http://www.zurinstitute.com/recordkeepingguidelines.html.]
  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.

New Year . . . New Plan

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I am in the process of deciding how to proceed with and utilize my blog during 2011. Since you are the consumers of the blog articles, I would very much appreciate your input about how I should do this.

  1. Are there particular topics I have written about that were particularly interesting or useful to you?
  2. Are there certain things you would like me to address?
  3. Do you think the blog is a waste of your time and mine and that I should just let it go?

Please share your thoughts with me. I would like this effort to be as worthwhile as possible. Your guidance will be greatly appreciated. Thanks for reading and commenting when you have the chance!

Kathy

Meaningful Use & Behavioral Health Providers

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I have been avoiding writing about the second draft of the Meaningful Use of Electronic Medical Records (EMRs) definition released by the federal Health IT Policy Committee on July 16. I had been hoping I would hear something that would make me believe the definition would in some significant way benefit our customers. I am disappointed to report that it still appears that the ARRA stimulus funds for adoption of EMRs will be largely unavailable to behavioral health providers, except psychiatrists, unless some change is made through regulation.

Just to clarify my statements above: ARRA provided $19 billion in funding for EMRs. $2 billion will be provided to the states to distribute for grants. Community Behavioral Health Organizations (CBHOs) are included in the eligible organizations for these funds. Unfortunately, it appears that this funding is going to be used by the states where they see fit. I have heard from a representative of at least one children’s psychiatric hospital who was told that funding would be used by the state to build Health IT (HIT) infrastructure and data exchange capability. They were informed that providers could get their funds from the incentives. I will be very curious to see how much (if any) of that $2 billion winds up in the hands of providers of any sort.

The larger part of the funding, $17 billion for Medicare and Medicaid incentives, is designed to encourage providers to purchase EMRs and use them to improve the care of their patients. Of the providers eligible to receive these reimbursements, the only behavioral health providers who are eligible are psychiatrists and certain nurse practitioners. They would purchase a system and then receive reimbursements for some or all of what they have spent depending on a variety of complex formulas. If you are a psychiatrist and you do not see Medicaid or Medicare patients, you are not eligible for funding. If you do treat these populations, you will only be able to get funding from one source, Medicare or Medicaid. The amount of reimbursement you can receive depends upon what proportion of your patients are Medicaid or Medicare recipients, along with other complex criteria.

Senator Jay Rockefeller of West Virginia introduced the Health Information Technology Public Utility Act of 2009 in late April. This bill was intended to assure that certain “safety net” providers like rural clinics and mental health providers could also access funds. That bill has not moved. Unless something happens in regulation, it is not likely that psychologists, social workers, mental health counselors, addiction treatment programs, psychiatric hospitals, or community behavioral health service providers are going to benefit from the stimulus funds to help purchase EMRs.

That said, the Health IT Policy Committee did seem to take into account the input they received from the public about the initial attempt at defining “meaningful use of EMRs”. They have drafted a plan that widens definitions, expands time frames, and provides more opportunities for providers to demonstrate that they are using EMRs meaningfully. Their PowerPoint presentation does a good job of summarizing their points. Details can be found in their updated grid and matrix.

1. The primary goal of the definition is to improve the outcomes of healthcare interventions through data capture and sharing and use of advanced clinical processes. They want providers to focus on health outcomes, not on software. HIT is to be a primary aid to healthcare reform, not use of software for the sake of earning incentive money.

2. It is the intention of the committee that there be a phasing in of meaningful use criteria. The public was concerned that if providers could not meet the 2011 criteria in 2011, they would always be behind the train. The committee now recommends that a provider who does not adopt an EMR until 2012 (or 2015) will start at the 2011 criteria and progress from there.

3. Changing work flows to assure the proper use of IT tools is an essential part of the solution. Trying to use CPOE (computerized physician order entry) can actually cause problems if there are not work flow modifications to make sure the process flows smoothly. An unintended consequence of CPOE in at least one study was diminishing of appropriate care because it was inconvenient to enter the order for the care.

4. Since data-based decision support is the real payoff of using an EMR, the committee wants to see this happen sooner, even it if means implementing only one rule in the decision making process.

5. Since engaging patients in their care is crucial to reduction in costs, providing access to an electronic version of their health record needs to be higher priority and come earlier in the process than previously envisioned.

6. Certification of software should be done by more than one body; CCHIT should not be the sole arbiter of which products should be certified.

While the Health IT Policy Committee has now presented their second draft of the “meaningful use” policy, it has until the end of 2009 to finalize the rules. It appears, however, that the direction is set. If you want to get some of the incentive money to help you buy an EMR, you will need to demonstrate that you can use that EMR and can report a variety of metrics to show how your practice is handling a number of issues. So far, none of those metrics are vaguely related to mental health.

Do you expect your organization/practice to be seeking incentive funding to purchase an EMR? How are you proceeding to assure that outcome? Do you think it is important for behavioral health to be included in the adoption of EMRs?

Just click on the title of this article and enter your comments in the box a the bottom of the page. Thanks for sharing your thoughts.

Death and EMRs: Disruptive events?

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The deaths of the past week have set me to thinking. The mother of a friend passed away early in the week followed by the wife of a family friend. Then, news of the death of cultural icon, Michael Jackson, was everywhere.

I come from a family and culture (New Orleans-based) where death is an intrinsic part of life. It very much affects those who are touched most directly by the loss, but it is also integrated into day-to-day life in such a fashion that life moves on with barely a ripple. The deceased is celebrated and mourned in one or multiple events ranging from wake to jazz funeral. Burial in above-ground graves and mausoleums (the water table in New Orleans is very high) caps off the events, and the cemeteries are daily reminders of the short-term nature of life. As with everything else in New Orleans, after death there is a party, but there is real disruption only for those immediately touched by the death. Life goes on.

I married into a family that shares the more traditional views of death held by most of American culture. It is not to be talked about too openly, lest it be invited to approach. And, as for most people in our culture, death is definitely considered to be a disruptive event, dislocating those related to the deceased from the ordinary course of life for an extended period of time. In fact, the disruption is frequently so severe that it is no surprise to those around the survivors that they are forever changed.

The term disruptive technology was introduced by Clayton M. Christensen in 1995 and together with his modification disruptive innovation has become a catch-phrase for technological change that is so radical that it dramatically alters the course of events that follow. If you read any articles about technology, you will come across the terms.

On the way to an event yesterday, we were listening to a podcast of The Week in Technology (TWIT) in which Twitter was discussed as a disruptive technology…disruptive to the field of journalism and to our whole way of communicating and thinking about news events. The techno-nerds who are the mainstay of TWIT are convinced that the immediacy of communication enabled by Twitter is and will continue to radically alter the way in which we receive information, likely becoming the jumping off point for even newer innovations in the realm of communication and information sharing.

I find myself wondering if Electronic Medical Records (EMRs) will not become the same kind of disruptive technology for our current healthcare system. Since EMRs have been around  for a while now, many would argue that they will certainly change healthcare, but do not reach the level of disruptive technology. But when I think about many of our customers in the behavioral health community and the radical changes to their organizations that will be required to move to EMRs and to use them in a meaningful way, I can imagine few more disruptive events.

Some would say that managed care had the potential to be just as disruptive…it certainly changed the way in which private mental health practices have conducted themselves over the last twenty years…but it did not intrinsically change the way in which the provider interacts with the recipient of healthcare services. The consumer may be seen less frequently and for a shorter total length of treatment, the managed care organization may refuse to pay for certain types of care (which the patient can then purchase with their own dollars), but the provider still sees the patient, assesses the problem at hand and provides treatment.

EMRs have the potential for changing that sequence of events. If used in a “meaningful” way, if decision support tools and treatment protocols that are based on scientifically assessed methods (evidence-based treatment) are incorporated into the EMR products and utilized by providers at the point of care in the way envisioned by the framers of HITECH, we will have a new healthcare system….or maybe not.

What do you think? Will widespread adoption of EMR systems be a disruptive innovation for healthcare? Do behavioral health EMRs have the potential to be disruptive technology for the mental health community?

Please add your comment by clicking on the title of this article and typing your thoughts in the comment box at the bottom of the page.

42 Months post-Katrina: Where are health records?

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I’m getting ready for a week of vacation in my hometown–New Orleans. As some of you who know me well may remember, my 89-year-old mother has been with us in Florida since Katrina-breached levees filled her New Orleans home with 8 feet of water. Our last visit was almost 22 months ago; it is definitely time for Mom to see family and friends who returned to LA after the storm.

Preparing for this trip in the midst of all the hubbub about EMRs and economic stimulus plans reminds me of those first few weeks after the storm. Mom was two months post MI when Katrina threatened and I was on my third post heart attack visit. When the mayor started talking about mandatory evacuation, we left Mom’s house with a change of clothes and her medications, and headed to my brother’s place in Louisville, MS. Three days later, when it became clear that we would not be returning to NOLA soon, we came here to Florida.

The first week post storm was spent buying a few clothes, shopping for doctors and getting prescriptions transferred to a local pharmacy. Fortunately, many pharmacies already shared data electronically in 2005, even when prescriptions were written by hand; but prescriptions were expiring and we needed a physician to write new ones. As we started going to appointments with a new primary care physician and a cardiologist, I was faced with the challenge of recreating 85 years of health history with my mother’s limited memory and my tangential recollections from a 600 mile distance. Mom was about half way through a cardiac rehabilitation program at the hospital at which she had been treated. Our local hospital was willing to have her participate in their rehab program, but they decided not to charge her rather than try to deal with Medicare about incomplete services for which there were no records.

At the end of Mom’s fourth week with us, I headed to Washington, D.C. for a meeting of the Software and Technology Vendor Association (SATVA) and to attend the National Summit on Defining a Strategy for Behavioral Health Information Management and Its Role within the Nationwide Health Information Infrastructure (Summit) co-hosted by SATVA and SAMHSA . When Tom Trabin, Ph.D. (then SATVA Executive Director) and others came up with the idea of a Summit, the need was only an abstraction for me. Of course mental health providers needed to be involved in the gradual move toward EMRs. By the time of the Summit, I had concrete first-hand experience with the reason for the meeting. My 85 year old mother and thousands of other New Orleans residents were completely without health records. Doctors’ offices and hospitals were flooded just as was her home. It was not even possible to reach her doctors, much less get information from them; they were displaced just as their patients were. The Summit pressed me to a concrete conclusion: behavioral health providers and consumers could not afford to be left out in the cold when catastrophe happens, and mental health could not let the general health field get too far ahead in the move to electronic medical records (EMRs).

After all, what physician or psychologist would be able to recreate a record from memory? And how many individuals carry an accurate health history in their head? The best anyone could do in 2005 was use health claim information from insurance carriers, Medicare and Medicaid. Frankly, for most physicians, it was too much trouble to attempt to obtain such information, even though a means of getting that data had been established. In some places that received large numbers of evacuees who had urgent healthcare needs and no family members with them, the network of access that was cobbled together from Medicare, Medicaid and VA claims databases allowed diagnosis and treatment of those with acute needs, but that took weeks to put in place. This destruction of health records became one of the most obvious reasons to press for a national system of electronic health records (EHRs), one that would not simply be washed away in eight feet of water.

So where are we 3 1/2 years later? If another Katrina-like catastrophe occurred tomorrow, would we be in any better position to treat evacuees based on information from an EMR or from a Personal Health Record (PHR)?

My guess is that we would be in just the same position we were in 2005. More physicians and hospitals are now using EMRs. The President and Congress have just appropriated 19 billion dollars for expanding the infrastructure and use of EHRs that we were discussing in 2005; but the reality is that we are nowhere near where we need to be to assure that continued care can be provided for general health or for mental health consumers. For the last 3 1/2 years there has been lots of activity, but today between 13% and 17% of provider organizations use EMRs; and there is still no system in place for sharing information among different organizations. Given a flood and no off-site backup of the electronic data, we would have exact duplication of the Katrina results.

Now that $19 billion that has been made available for meaningful use of EMRs over the next few years, we can expect more frenzied activity and attempts to implement EMRs in more organizations. We can hope that a simultaneous effort will be made to assure that the information in those records will be protected from destruction and can be shared from one organization to another. Where will you be in this process? Is it time for your organization to start to consider implementation of a behavioral health EMR? Are you obtaining the necessary information to qualify for federal funding? How will your clinical records be handled 3 1/2 years from now?

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