Behavioral Health

Can effective healthcare IT reduce hospital costs?

The focus of federal efforts to incentivize healthcare IT adoption has primarily been on electronic health records (EHRs), which are oriented around hospitals and physician offices. Moving forward, EHRs will remain the anchor technology as data from other devices and applications flows in and becomes both available and comparable.

It’s become readily apparent that healthcare IT is much broader than EHRs alone. Increasingly, healthcare IT is a web of interconnected devices and applications that can feed data to the EHR. So, instead of focusing intently on how healthcare IT can alter inpatient safety and quality, we’re better off looking at technology as all the tools patients and doctors can use to maintain and improve health.

Why might this shift in focus be important? One obvious reason is that hospital and emergency care are expensive. The average cost for a single inpatient day in the United States is more than $2,200. The average cost of an ER visit is about the same—$2,168—without being admitted.

The better reason is that hospital visits often mean something has gone wrong. Sure, some hospital stays or visits are required because life is messy and people get in accidents. But others are the product of preventable scenarios. Instead of focusing on crisis-scenario work, perhaps there is wisdom in focusing on the more mundane tasks technology can perform to keep people out of the hospital.

How, specifically, can we use IT to make patients better shepherds of their own care?

  • Identify at-risk patients. Age, ethnicity, health history, gender, geographic location and other population health data give healthcare professionals a pretty good idea of who will get sick. Obviously, primary care providers also have a significant role to play when it comes to identifying potential health problems and engaging the patient in a plan to avoid them.

    When it comes to at-risk patients, technology is essential but not sufficient on its own. A better approach might be a care management scenario that combines big data analytics, the collaboration of multiple providers,  and human insight. 

  • Monitor patients’ vitals and welfare. For a while now, wearable devices have given healthcare the ability to track patients outside of the hospital and clinic. That tracked data can be relayed wirelessly back to the EHR and is available to physicians when they check patient status.

    Remote patient evaluation is also available more directly via telehealth. Through remote consultations and evaluations, a physician can usually determine whether a patient should come to the hospital or is fine at home. As is often mentioned, telehealth offers great potential in terms of treating patients in remote areas where hospitals and specialists are few. 

  • Remind patients of appointments. No-show rates for patients vary wildly—anywhere from 5 percent to 55 percent—with similarly varying impact on patient health. Sometimes a patient misses a cardiac stress test and shortly thereafter suffers a heart attack. Other times a routine checkup is missed with no physical fallout.

    The point is that patient portals and regular communication provide services both banal—the patient is simply reminded that they have an appointment—and potentially essential in the case of a cardiac diagnostic. Regular communication in advance of a test is an opportunity to provide patients with reassurance and more information on the potential benefits of attending the appointment.

  • Empower them to manage their own care. Especially regarding behavioral health, technology enables patients to learn self-management techniques that improve coping skills and ideally prevent incidents requiring hospitalization. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, mobile phone applications can remind people to take medications, track heart rates, help with stress and anxiety, and improve thinking skills, to name but a few benefits.

    It’s limiting, however, to think of self-managed care as essentially behavior health-related. All patients can benefit from technological assistance with taking medications regularly, improving dietary choices, monitoring blood pressure and getting some exercise. All of these daily activities could help keep someone out of the hospital.

  • Provide educational information. The internet is a jungle of information, some of it benign and some much less so. Hospitals and practices can direct patients toward reliable sources and can provide their own via PDF documentation and the patient portal. In fact, the internet is both an animating and potentially complicating factor in patient care, requiring providers, perhaps especially nurses, to evaluate information patients bring to appointments and correct as necessary. 

Of course, the ultimate focus in reducing hospital admissions is on patient health and welfare, but the corollary is runaway health costs in the United States and the need to wrestle them into submission. Once hospital admissions take place, things get expensive, making just about all efforts leading up to the hospital visit more attractive and cost effective.

The federal government (CMS, HHS) has made reducing hospital readmissions a primary objective and a criterion impacting hospital reimbursements. But there can’t be a readmission if admission is avoided in the first place. Moving forward, integrated, aware health systems will focus as much on preventing hospital visits as they will on making sure patients don’t come right back.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

5 ways technology makes behavioral health care better

Are you old enough to remember the pre-concert security searches for recording devices that were once part of every live music experience? Yes, musicians once had some semblance of control over bootleg audio and video.

But the proliferation of tiny hand-held computers that happen to also make phone calls ended all that. Now, tossing music-lovers who pull out a phone to record would empty entire arenas save a few luddites with flip phones and mullets.

Sometimes silently, other times with great fanfare, technology has wormed its way into almost every aspect of life. Much has been written about the use of electronic health records in healthcare, for example, but EHRs are just one example.

In behavioral health, EHR adoption lacks financial incentives so the rate of adoption has lagged that of acute care. And still technology creeps into the way we provide behavioral health care, in many ways transforming and often improving treatment, compliance and reporting.

One could argue that the potential for positive disruption is greater in behavioral health than in any other subset of medicine and healthcare. So how, exactly, is technology upsetting the behavioral health apple cart in beneficial ways?

  1. Improving correlation of health information: There is a strong likelihood that a patient with bipolar disorder or a similar affliction is also self-medicating with drugs and alcohol. Sure, a caregiver somewhere along the way might notice the physical signs of abuse, but they also might not. A comprehensive EHR that includes patient data from coordinated providers would provide that information, just as it would when the bipolar patient shows up at the ER with a broken arm.

    According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes. Therapists might sometimes have the luxury of just treating a mental illness, but around half the time they will also be working with an addiction problem and must aware of both.

  2. Making care available outside urban areas: The numbers suggest mental health counselors are jockeying for clients in urban areas and scrambling to meet overwhelming demand in rural sections of the country. Rates of alcoholism, opiate abuse and generally risky behavior are higher outside of major cities, creating a burgeoning healthcare crisis in the parts of the economy oriented around agriculture and energy.

    With few promising alternatives, much of the push to resolve America’s rural health conundrum is now focused on telehealth, and with good reason. Telehealth has proven effective thus far in treating depression and PTSD. According to a 2012 Institute of Medicine report, telehealth also increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. 

  3. Boosting the bottom line: A comprehensive EHR combined with robust revenue cycle tools and services ensures that behavioral health care providers are compensated more reliably for the care they provide.

    “An EMR is an investment because it provides long-term benefits and may be an important tool for reducing the cost of expenses,” writes Carol Turso in Behavioral Healthcare.

    Turso uses the example of a social services organization that over three years after implementing an EHR reduced bad debt by 93 percent, lowered outstanding accounts receivable of more than 151 days from 24 to 9 percent, and trimmed the time staff spent per week entering remittances and payments from 40 hours to 10 minutes. In every instance, these EHR benefits improve the organization’s bottom line. Even if they don’t technically create new revenue, they are still financially relevant.

  4. Enabling self-directed care: At its core, self-directed care is empowerment focused on dealing with pain and frustration, getting regular exercise, eating well and communicating with counselors and family. Self-directed care engages the patient more fully in the care process, even in some instances allowing patients input on how and where to spend the money applied to their treatment.

    In recent years, the self-directed care model has gained more currency in the provision of behavioral health care. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, technology, especially mobile phones, offers support and assistance. 

  5. Giving kids something to do: Do mobile devices keep kids off drugs? The jury is still out, but it’s one explanation for a steady downward trend over the last decade of teenagers experimenting with drugs and alcohol. Correlation, of course, is not causation, which is why the National Institute on Drug Abuse plans to make this the subject of a study over the next several months.

    While many teenagers seem as addicted to mobile phones as they might be to marijuana, parents will probably rest easier knowing the former might be preventing the latter.

The proliferation of technology, especially in healthcare, is something that must be monitored over time and re-evaluated regularly. As some healthcare economists have pointed out, technology drives up healthcare costs more than any other factor.

But behavioral health, specifically, will never have to invest in massively expensive tools like MRI machines, creating an opportunity for the grassroots use of relatively affordable handheld and desktop technology that over time can affect measurable change in the lives of patients.  

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

When illnesses collude: How comorbidity threatens American healthcare

Comorbidity is not a word heard every day—not even in healthcare, where it applies. But researchers and physicians, assisted by IT-derived diagnostic data, have come to understand that comorbidity is essential to understanding and managing population health, especially among vulnerable populations challenged by mental illness and addiction.

A patient with comorbidity has at least two chronic diseases at the same time that interact in such a way as to worsen the impact of each illness on the individual. Imagine irritable bowel syndrome or Crone’s and diabetes working in tandem, for example, and it’s not hard to see how comorbidity becomes a tag-team bludgeon.

Among the total population of the United States, 25 percent have multiple chronic conditions, according to the Centers for Disease Control and Prevention (CDC). Of course, those chronic conditions are not limited to the physical. Once we include mental illness and substance abuse in the definition of comorbidity, rates rise dramatically and are often more debilitating.

There is simply no denying that even the most common mental illness creates the risk of comorbidity with drug and alcohol abuse. According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes.

In this environment, doctors and the healthcare system are not tasked with just treating a physical illness or three. They also have to treat a physical challenge that may have been neglected due to mental illness made worse by substance abuse. Or maybe they’re trying to wean a patient off heroin used to deal with chronic pain after the OxyContin subscriptions ran out.

It’s this complex self-medication dance that regularly doubles back on itself and dramatically ratchets up costs in terms of both healthcare dollars and lives. Opiate-related deaths just recently surpassed those from gun violence, and healthcare costs rose 3.4 percent last August, the highest one-month rise since 1984.

“On average individuals with chronic medical conditions incur health care costs two to three times higher when they have a comorbid substance use disorder compared with individuals without this comorbidity,” wrote Surgeon General Vivek Murthy in his recent report on addiction in America.

No, mental illness does not always lead to substance abuse and an often irreversible downward spiral. But addiction always makes both physical and mental illnesses far worse, even if we cannot determine causality or directionality.

A survey by the National Institute on Alcohol Abuse and Alcoholism, for example, identified comorbidity in a majority of respondents. A separate study by the NIAAA found that 56 percent of subjects with bipolar disorder also practiced some form of alcohol abuse and were more likely to have medical comorbidities like lung and breathing issues because smoking is so common.

How can we deal with mental illness to try and avoid substance abuse and medical comorbidity?

  • Catch it early. “… research indicates that 90 percent of people who develop a substance use disorder started their use before age eighteen,” writes Alexa Eggleston of the Conrad Hilton Foundation in a recent Health Affairs blog post. Eggleston speaks of substance abuse in general, but the risks are greater in the teenage years, when most mental disturbances manifest, making increased awareness even more necessary.
  • Initiate treatment. Addressing a mental issue is more straightforward before comorbidity becomes a factor. If mental illness and substance abuse comorbidity happens, treatment should focus on both issues at once, according to the National Institute on Drug Abuse.
  • Break down silos. The unfortunate tendency in healthcare going back decades has been to silo information and care. Treatment has tended to focus on independent specialists treating separate aspects of the patient condition without fully addressing how they impact one another. That must end. The placebo effect, for example, shows us that the brain and the body are not separate and that treating them as unrelated makes as much sense as changing the oil on a car with four flat tires.

To be sure, changes to the way we provide care—paying for value, Patient Centered Medical Homes, ACOs, HIEs, etc.—have gained great momentum that should continue. As mandated by the recently passed 21st Century Cures Act, interoperability among healthcare IT systems must become a reality so ER docs can see when a patient is bipolar and family practitioners know immediately that their new patient is on anti-psychotics.

Annually, the United States spends $35 billion from both public and private payors to treat substance misuse, but that’s a small fraction of the amount addiction extracts from American society in terms of services for the homeless, work absenteeism, broken families and other types of fallout. In total, substance abuse is estimated to cost the United States more than $400 billion each year, an amount that is 2/3 that of the Pentagon budget.

We are currently in the midst of one of the worst drug-addiction epidemics the nation has experienced. No, integration of patient record systems and patient care protocols will not prevent the destructive chain of events that leads to substance abuse, but becoming more alert to the frequency and severity of comorbidities may enable us to see warning signs sooner, share information and work more interactively with other caregivers, and more effectively improve patients’ overall health and quality of life. And this multi-pronged approach to quality of care will very likely minimize the costs to society in the process.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Cures Act: A bag of holiday gifts for healthcare

On Tuesday, President Obama signed the 21st Century Cures Act, codifying a broad and far-reaching effort to achieve medical breakthroughs in Alzheimer’s and other debilitating afflictions through improved, streamlined, well-funded research.

The Cures Act gives particular attention to cancer and Vice President Joe Biden’s Cancer Moonshot initiative, which hopes to transform research and make certain varieties of the illness either manageable or history.

“God willing, this bill will literally, not figuratively, literally save lives,” Biden said at the signing ceremony. “But most of all what it does … is gives millions of Americans hope. There’s probably not a one of you in this audience or anyone listening to this who hasn’t had a family member or friend or someone touched by cancer.”

The Cancer Moonshot illustrates well how most of the Cures Act focuses on research and additional funding for the National Institutes of Health and similar agencies. But it also focuses on bettering the current provision of healthcare by improving behavioral health care and healthcare IT.

Viewed from a high level, Congress is focused on stemming the tide of mental illness and opioid addiction in America, as well as making sure healthcare information flows freely and safely among providers to improve patient care. Read on for highlights.

Mental Illness and Addiction

Via the specific proposals below, the Cures Act endeavors to better fund mental health care and opiate addiction, improve leadership and planning, ramp up research, enforce parity and improve preparedness among police and in the legal system.

  • Over the next two years, the Cures Act provides $1 billion in state grants for opioid abuse prevention and treatment. Specific parts of the proposal include prescription drug monitoring, healthcare provider training and better access to treatment programs. Indeed, block grants to state agencies are clearly aimed at helping individuals break out of the addiction cycle that so often includes homelessness and limited family support.
  • Grants will also go to higher education and professional training programs to put more mental health professionals in the field.
  • The Act also creates new positions—an assistant secretary for mental health and substance use, and a chief medical officer—in the Substance Abuse and Mental Health Services Administration (SAMHSA).
  • Apparently not a sanctioned SAMHSA component previously, the Center for Behavioral Health Statistics and Quality is now codified in the Cures Act, as is the requirement that SAMHSA create a strategic plan every four years to identify priorities and strengthen the mental health workforce.
  • Mostly through reauthorizations, the Cures Act provides funds for mental health programs that pay specific attention to some vulnerable populations: college students, women and children.
  • Mental health parity, already a law but sometimes inadequately enforced, will become more of a focus for HHS, which is being asked to draw up a federal and state compliance action plan.

Healthcare IT

While there are efforts in the Cures Act to improve the functionality of EHRs and access to records for patients, the real focus is on improving the flow of information.

  • Apparently fed up with allegations of information blocking, Congress included in the Cures Act $15 million in funding for improved interoperability and less information blocking. Some of the money will support a voluntary framework for information exchange and some will go to HHS to investigate claims of information blocking and punish the blockers to the tune of $1 million per violation. The Government Accounting Office is also required to evaluate patient access to personal health information and why it might sometimes be difficult to get.
  • Congress is also requiring HHS to change the terms of Meaningful Use to include interoperability. Moving forward, healthcare IT vendors must develop application programming interfaces (APIs) and apply real-world tests of interoperability to EHR systems.
  • If the Cures Act has a measurable impact, EHRs will become more patient-centric. Incorporated language speaks to making patient records more simple and easier to use, and continuing to grow Health Information Exchanges (HIEs) to expand patient access to care.
  • A new HIT Advisory Committee will make recommendations to the national coordinator on a host of healthcare IT concerns. Of particular interest will be the segmentation of data so that only select parts of a patient record can be shared and sensitive data related to mental illness and drug addiction can be closely controlled.
  • The Advisory Committee will also have the authority to make recommendations on population health, healthcare for children, telemedicine and other potential improvements to healthcare available through IT.

At nearly 1000 pages, the Cures Act obviously includes much more than the greatest hits included here. The curious might visit this highlights document and find specific objectives that perhaps are more relevant and important.

As with all federal legislation, efficacy is measured by impact over time, not number of pages or total appropriations. With the Cures Act, we can hope that the grant money will make a significant difference at the local level and that patient health information will flow more freely between coordinated providers. A cancer breakthrough wouldn’t hurt, either.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

Cures Act is a strong mental health vaccination. Booster shots required.

Remember that the two things you don’t want to watch being made are sausage and law. Then recall that while the process for both may be unappealing and seem incongruous, the product is not always so.  

Take the 21st Century Cures Act, for example, which is a lengthy (996 pages) piece of legislation (summary here) that focuses primarily on health-related scientific research and medical devices. It also broadly outlines the terms for an upcoming drawdown of America’s strategic petroleum reserve, which may look like a rider but is actually a way to pay for the bill.

The sale of crude will also help fund mental health and addiction treatment, about which the Cures Act has something to say thanks to language appropriated from the Helping Families in Mental Health Crisis Reform Act. That bill passed the House earlier this year but has languished in the Senate since.

It’s encouraging to see Congress address mental illness and addiction, and the Cures Act works to address many of the issues that plague American mental health care and bleed into acute care as well.

Read on for more on what the Cures Act does and doesn’t do to improve mental health care.

What does the Cures Act do for mental health care?

  1. Provide More Money: Over two years, the Cures Act provides $1 billion in block grants to the states for opioid abuse prevention and treatment through prescription drug monitoring, prevention programs and healthcare worker training. It also provides or reauthorizes a host of other targeted grants focused on specific goals and populations, including treatment of students on college campuses.

  2. Create New Leadership and Planning: The bill establishes a new assistant secretary for mental health and substance use to head the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as a chief medical officer within SAMHSA to help with program creation and development. 

  3. Promote Cutting Edge Research: Moving forward, a new National Mental Health and Substance Use Policy Laboratory (NMHSUPL … whew!) would be responsible for focusing evidence-based, scientifically oriented treatment on mental illness and addiction. The laboratory would also identify and respond to regionally specific mental health and addiction challenges.

  4. Push Parity: The Cures Act puts the onus for verification of compliance with parity legislation—the requirement that insurance policies cover mental and physical health equally—on Health and Human Services (HHS), Labor and Treasury. Down the road, the Government Accounting Office and CMS will evaluate whether or not parity compliance is happening. 

  5. Support Mental Health Training in the Legal System: Approved use of existing funds would empower law enforcement to create mental health crisis intervention teams and pay for targeted training. Additionally, the Cures Act requires the attorney general and courts to create a drug and mental health court pilot program.

What does the Cures Act NOT do for mental health care?

  1. Enable Integration with Acute Care: Despite there being funds for many programs, none were appropriated for expanding use of EHRs in mental health facilities. It seems like an omission, especially given the success of EHR adoption in acute care hospitals and the interoperability requirements included in other sections of the act. Interoperability is great and overdue, but it should be spread across the continuum of care to maximize impact.

  2. Add Beds: This isn’t a completely fair criticism, given that there is grant funding to states in the Cures Act that perhaps could be used for new facilities with more beds. But there isn’t a mandate with supporting funds to make up for the 4,500 public psychiatric beds that were lost between 2009 and 2012 and pretty much remain so. Indeed, when the need seems to be increasing, the number of psychiatric beds in the U.S. remains at record lows, contributing greatly to homelessness in urban areas and misuse of emergency department resources.

  3. Expand the Pool of Therapists: Outside of urban areas, professional therapists are hard to find and referring physicians have few options. Federal programs already exist that give teachers and doctors financial incentives (loan forgiveness) to work in areas where their skills are most needed. It seems like doing the same for therapists of various stripes—assuming such programs don’t already exist—is warranted. States could conceivably use grant funds to accomplish this goal, but federal law could offer more support. 

  4. Appropriate Enough Money: Looking at the number alone, $1 billion looks like a lot of money. As a sliver of the federal budget, and given the mental health and addiction challenges plaguing states, it may prove inadequate without viewing it as a down payment on a larger commitment. According to Robert Glover, executive director of the National Association of State Mental Health Program Directors, from 2009 to 2012 the states cut roughly $5 billion in mental health services, so 20 percent of that total at best may be restored.

Given what we know in the 21st century about mental illness—how common it is and how much human potential and productivity it drains from society—it’s not hard to envision behavioral health and addiction issues as some of the nation’s most daunting challenges.

But the 21st Century Cures Act, while focused on improving healthcare through better, more rapid research, perhaps tries too hard to be all things to all people. It won’t be. As with most legislation, the Cures Act will hopefully establish a foundation on which additional legislation can build. Subsequent legislative efforts should focus on expanding the pool of beds and therapists, and on integrating with acute care.

Let’s make sure those changes happen before there is a 22nd Century Cures Act.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

A new political era, but no reason to retreat from behavioral health IT benefits

It’s the season of post-campaign predictions. This week, most healthcare IT fortune tellers and sages are taking a shot at predicting what Trump will do with healthcare in general and healthcare IT specifically.

The (sort of) verdict?

For the most part, few believe the president-elect will make dramatic changes to Meaningful Use and HITECH. He didn’t mention them during the campaign. (The Affordable Care Act, aka Obamacare, he mentioned a lot, but that’s a different story.)

Even so, it’s still hard to believe a President Trump and Republican Congress will authorize more money for EHRs in mental health facilities. After the campaign, it’s hard to envision more spending on anything unrelated to the military, illegal immigration, infrastructure and maybe indicting Hillary Clinton.

Mental health organizations should not be deterred from acquiring a complete EHR, even though federal help may not be on the way. With attention to specific strategies—some of which focus on improving organizational function and not specifically EHR acquisition—cost-conscious mental health organizations can acquire a healthcare IT system without engaging in financial risk.

  1. Don’t buy software. In more technologically sophisticated industries, the idea of buying software and loading it on your computer is nearing extinction. In its place is software-as-a-service (SaaS), also sometimes called web-based, on-demand or hosted software. SaaS removes the challenges of paying huge sums upfront for software, acquiring expensive hardware and going through the lengthy and tedious implementation process.

    The SaaS approach gives smaller organizations access to enterprise grade hardware that would normally be unaffordable and makes it possible to acquire comprehensive EHRs you can pay for from the operating budget.

  2. Invest in revenue cycle solutions and services. When evaluating EHR providers, don’t focus only on the clinical side of the system. Implementation and maximization of revenue cycle solutions, services and practices dovetails nicely with adoption of an EHR and establishes the technological foundation for improved financial performance.

    Robust revenue cycle support reduces overhead, ensures rapid and accurate billing of payers and patients, and tracks performance indicators. The combination of a subscription service EHR and better revenue cycle management creates the potential for healthcare IT adoption that doesn’t expand the overall working budget.

  3. Choose a solution with specific behavioral health functionality. You already know that treatment of mental illness is not the same as caring for physical health. Make sure your prospective EHR vendor knows that as well as you do. In an inpatient mental health environment, caring for patients is often a team task, so make sure the EHR you consider enables every member of the team to both access and contribute to a treatment plan.

  4. Become intimately familiar with mental health parity laws and payer policies. Yes, mental health parity is federal law, but we’re not yet at a place where the law is being observed and respected equally by all payers. Familiarize yourself with both the law and the existing policies of the major payers so you can anticipate what will and will not be covered, and so you can go to bat for patients when insurers are not paying for things the law says they should.

    As with selecting a revenue cycle solution, knowing what is and should be covered gives your organization the knowledge required to tailor solutions and ensure you don’t provide are that won’t be reimbursed.

  5. Choose an EHR vendor organization that you know will be your partner. In every facet of healthcare, collaboration is the trait that best serves the patient. As a behavioral health care provider, you know that coordination among all members of the care team yields the most positive results.

    That same spirit of shared responsibility is not always evident in relationships between providers and IT vendors. Some are interested more in constraining your choices than enabling them; others simply install the system without offering sufficient training or suggestions about how to change what you do to maximize system efficacy. Make sure that, through your extensive due diligence and in-depth review, you and your vendor share a similar commitment to quality care and customer service excellence.

invariably, your organization is going to want to pursue strategies unique to your facility and staff. Whatever these may be, you’ll find them to be much more successful if you circulate the ideas extensively before starting active pursuit. Create buy-in amongst all constituents so that no one is unaware and feels left out, which invariably causes resentment.

The healthcare IT trade publications are regularly filled with stories about multi-million dollar contracts and significant cost overruns. Don’t be frightened. Many of your fellow behavioral health colleagues have already acquired an EHR and are making it work by pursuing specific purchase strategies combined with organizational priorities. Look around and you’ll see plenty of proof that your organization can achieve the same goals.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

Category: Behavioral Health

How can we measure health system success without including mental health care?

If community hospitals are a general barometer of health in the surrounding area, the emergency room is the canary in the coal mine. Viral outbreaks, increases in violence, loss of health insurance from local layoffs—all are social ills that make their presence known first in the ER.

Based on recent ER studies, the U.S. is on the cusp of a full-blown mental health crisis.

According to a recent survey of more than 1,700 emergency physicians by the American College of Emergency Physicians (ACEP), three-quarters of ER docs evaluate at least one individual per shift who requires hospitalization for mental illness. Slightly more than 20 percent say patients wait from 2 to 5 days for an inpatient bed. Only 16.9 percent of ERs have a psychiatrist to call in emergencies, and 11.9 percent have no one at all to call when mental illnesses erupt in the ER.

"More than half (52 percent) of emergency physicians say the mental health system in their communities has gotten worse in just the last year," said Rebecca Parker, MD, FACEP, president of the ACEP. "The emergency department has become the dumping ground for these vulnerable patients who have been abandoned by every other part of the health care system."

The most recent survey results dovetail with a separate study presented at ACEP16 that looked at ER use between 2002 and 2011. From that review, we know that psychiatric visits to emergency rooms jumped 55 percent—from 4.4 million to 6.8 million—during the period evaluated.

The experiences of emergency physicians confirm that America is in the midst of a mental health crisis that requires time and attention. While rebuilding mental health care, we also need to use that process to learn. The state of mental health care can be both a measure of overall healthcare system progress and a cautionary tale about the unintended consequences of using information technology.

Healthcare is functioning when the mentally ill get treatment.

Yes, healthcare is in the midst of a revolution encompassing digitization of data, new payment models, the use of wearable devices and a host of other changes. It often feels like the entire healthcare enterprise is subject to some kind of change.

And yet none of the current overhauls will keep the mentally ill from showing up in emergency rooms. The House has passed legislation intended to help improve the mental health care system and, in part, alleviate some of the stress on emergency services. Hopefully the Senate will do likewise.

What would system changes that benefit the mentally ill look like, beyond a drop in ER visits? Probably something like a patient-centered medical home.

The mentally ill would have a psychiatric professional who would be contacted in the event of an episode at the ER. A network of care givers, friends and family could provide some confidence that proper care would follow the ER visit. An integrated healthcare IT system would give ER docs the data they need when a man with bipolar disorder wanders in, and it would let the man’s physician know he perhaps forgot to take his meds and had an episode.

Current fractures in the mental health care system mean those who enter the ER with a mental illness are often admitted for lack of local mental health services and support.

When the mentally ill get the care they need, we will know that the intersecting but uncoordinated goals of parity, interoperability, coverage and coordination have finally been met.

Digitized mental health care is better mental health care.

It’s not just that EHRs and other forms of healthcare IT give ER docs more information at the point of care about mentally ill patients. Digital systems that incorporate complete patient records also back up behavioral health clinicians and empower them to provide better care.

A six-year study of mental health specifically by researchers at the University of Southern California’s Keck School of Medicine showed that electronic charting yielded noticeably better clinical documentation. The complete documentation of visits and procedure codes rose from 60 to 100 percent. The timely completion of records improved quality of care and proved an asset in clinical training.

More than just clinicals improve with healthcare IT. Billing and reporting, both essential for financial viability, are more straightforward tasks with electronic support.

“The way things are going, it’s almost going to be impossible to not have an EHR,” Jennifer D’Angelo, chair of the new HIMSS Long Term Care and Behavioral Health Task Force and vice president of information services for Christian Health Care Center in New Jersey, told Behavioral Healthcare. “From an interoperability standpoint, and from a reimbursement standpoint, it’s being required. All levels of care will need to have an EHR for care coordination among all providers.”

Caveat: System security and personal privacy are more crucial with mental health data.

If your patient records are compromised or inappropriately shared, your primary concern is not that people will know you had an appendectomy in 2006 and a mole removed in 2011. You’re most worried about all the other information that will make it easy for the thief will misuse your information or even assume your identity.

And then there’s the experience of Canadian Lois Kamenitz, whose patient record showed that she attempted suicide in 2006. When Kamenitz tried to enter the United States in 2010, U.S. Customs and Border Patrol pulled her aside and would not let her enter the country until she filled out lots of paperwork, paid an American doctor $250 to process it and signed a document saying her medical records would become the “permanent property of the United States.”

Her personal privacy violated in a most unexpected scenario, Kamenitz found out the hard way that personal health information could be used against her after Toronto police shared a database with the Department of Homeland Security. Her experience is not an anomaly. It's not just that a person’s health information could be improperly exploited if accessed by non-clinical reviewers. Non-behavioral health clinicians can also mistakenly complicate or skew physical evaluations, procedure orders and prescriptions. 

So, is the paradox of EHRs and behavioral health patient integrity—improve patient care, increase patient vulnerability—a challenge that requires special attention? Yes, it does. Of course healthcare’s standard is that ALL patient records must be secure, but the sensitive nature of mental illness can often necessitate special diligence beyond what works to secure patient data in acute care. Public perceptions of mental illness frequently include fears of violence or unexpected behavior; at the same time, mentally ill patients fear that public exposure may threaten their employment and community relationships.

Clearly, there are policy issues that have yet to be worked out. Canada changed a policy that will hopefully make what happened to Lois Kamenitz rare or maybe impossible. Let’s hope that the trial-and-error process of policy development works itself out quickly with as few casualties as possible.

While there is much work to be done in simply improving mental health care and the lives of those who suffer, we must put IT and data security measures in place to ensure that citizens are not punished once by their mental illness and then again by a society that fears them. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Are you maximizing EHR value by minimizing costs?

Most of the time, discussions about behavioral health EHR costs focus almost exclusively on the actual outlay for the system, implementation and ongoing maintenance. Maybe hardware is also included when the behavioral health hospital in question doesn’t have the requisite foundation.

But there are economic efficiencies enabled by an EHR that behavioral healthcare facilities would do well to embrace in determining what an EHR solution actually costs. Hard costs are reduced when coupled with reductions in pre-EHR inefficiencies that can effectively be addressed using the healthcare IT system.

When deciding whether or not your behavioral health hospital can afford an EHR, there are a few different areas to consider in fleshing out a complete and accurate ledger of total costs and savings enabled by the healthcare IT system.

Paper

Let’s start with the most mundane potential source of savings—the elimination of (optimistic) or dramatic reduction in (realistic) the use of paper.

Before EHRs, medical record keeping was a paper-based, manual project that required paper, ink, printers, filing cabinets or shelves and people to manage all those records. With EHRs, your patient records become readily available to clinicians without an extensive search. Updates to the record don’t require the printing of more documents.

Figuring out how much savings the move to an electronic environment might create is as simple as determining annual expenditures on related supplies before the EHR goes in and comparing that with paper, ink., etc., purchases after the system is fully in use.

Keep in mind that while the elimination of paper records may reduce labor in one area, the adoption of healthcare IT may expand labor in another. Labor costs may stay the same or potentially rise.

Duplicate and Unnecessary Testing

Cleveland Clinic worked with their EHR vendor to build hard stops into the system. Now, when a doctor tries to order a duplicate test, they’re blocked and instead see the most recent results of the test they’d tried to order. Originally starting with just a few, the list of lab tests that should not ordered more than once daily ballooned to more than 1,300.

After nearly two years using the hard-stop approach, Cleveland Clinic had prevented around 18,000 duplicate tests and saved close to $300,000 in lab costs.

By limiting who can order complex molecular genetic tests, the clinic also saved more than $700,000 over two years. Adding a genetics counselor and molecular genetic pathologist in the lab to advise physicians on which tests to order saved another $820,000.

This is how one outpatient organization used their healthcare IT system to manage costs. The same opportunity exists for behavioral health hospitals that have implemented a comprehensive healthcare IT system. What can you learn from the experience of other providers? How creative can you be with your own system?

Medical Errors

“Health care in the United States is not as safe as it should be—and can be,” read the opening lines of the Institute of Medicine’s groundbreaking 1999 report To Err is Human. “At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies.”

Earlier this year, two Johns Hopkins clinicians estimated that medical error is actually the third leading cause of death in the U.S., after heart disease and cancer, and is the cause of nearly 10 percent of all annual deaths.

In behavioral health, data is harder to come by. A Medscape study that looks at medication errors (prescription, transcription, dispensing, administration) in psychiatric facilities yielded three interesting results: behavioral health providers write a lot of prescriptions, most psychiatric medication errors are high risk and self-reporting leads to vastly underestimated numbers of medication errors.

What do medical errors cost? The IoM report estimated that preventable injuries cost from $17 to $29 billion annually. A separate study of medication errors in a large teaching hospital pegged the annual cost of errors at $5 million and estimated that the total annual cost of errors in all acute care facilities was $20 billion.

To be clear, medical errors and medication errors are not synonymous—the latter is a subset of the former. But every facility has some of both, every incident is very expensive, and properly implemented and configured EHRs reduce medical errors, saving your organization significant amounts of money in the process.

Of course, saving patient lives is more important than saving money, which is why medical errors are such a heated topic in healthcare. But in economics, every mistake, every duplication, every inefficiency has a cost, and those costs accrue to both the individual organization and society at large.

Look at the functions of your behavioral health organization in economic terms and embrace the opportunity to evaluate and create efficiencies through the EHR. By finding more efficient ways to approach daily tasks, you can increase patient and clinician satisfaction, and reduce the costs associated with operations. 

Category: Behavioral Health

Yes, you can get ROI from a good behavioral health EHR, even without Meaningful Use

No, there is no Meaningful Use for behavioral health hospitals, and yes, some mental health clinicians remain skeptical about the proposed value of electronic health records (EHR).

And yet a steadily increasing number of behavioral health facilities nationwide have adopted an EHR to improve patient care and organization performance. According to a recent Behavioral Healthcare survey, most are satisfied with the decision to make an EHR part of their daily routine.

So, does that satisfaction make it a wise value proposition to adopt a behavioral health EHR? This highly relevant question about return on investment (ROI) is not limited to behavioral health facilities, but it might be a more pressing concern for organizations that cannot count on federal subsidies.  

What counts in determining ROI?

Because behavioral health care is complex and, more importantly, because it measures value in many non-monetary ways, we have to look at both quantity and quality.

“Some organizations have difficulty determining their EMR project's ROI,” writes business development executive Carol Turso in Behavioral Healthcare. “Common reasons for this are failing to see an EMR's strategic benefits and considering the initial cost as an expense rather than as an investment … An EMR is an investment because it provides long-term benefits and may be an important tool for reducing the cost of expenses.” 

Turso uses the example of a social services organization that over three years after implementing an EHR reduced bad debt by 93 percent, lowered outstanding accounts receivable of more than 151 days from 24 to 9 percent, and trimmed the time staff spent per week entering remittances and payments from 40 hours to 10 minutes. In every instance, these EHR benefits improve the organization’s bottom line. Even if they don’t technically create new revenue, they are still quantitatively relevant.

Qualitative improvements save time, prevent adverse medication events and reduce errors, which saves money. As the federal government shifts to a reimbursement model based on quality and patients vote with their feet, the qualitative approach starts to look more like a quantitative imperative.

How do non-clinical factors impact the evaluation of ROI?

You can build it, but they may still not come.

So, it’s difficult to exaggerate the importance of behavioral factors in ensuring the value of your behavioral health EHR. You must create buy-in, make clinicians feel as though they have a voice in the process, train everyone effectively on the system and take feedback on how to improve the solution and workflows after go live.

“Realizing full value of the [EMR] system typically depends not only on successful deployment of the system but also on adaptation of other organizational processes and workflows,” says an Institute of Medicine (IoM) paper that seeks to create a standard model for assessing the value of EHRs. “Functionality is also enhanced or constrained by the quality of implementation, including user training and acceptance, as well as the universe of technology with which it is used.”

The good news is that, for most behavioral health hospitals, the investment in EHR seems to be money well spent.

According to the Behavioral Healthcare survey mentioned above, the majority of those with an EHR are satisfied and putting the system to good use. Among all respondents, 23.6 percent said the EHR they use improves patient care, 18.1 percent cited the elimination of paper storage as a prime benefit, and double-digit percentages identified improved care, reimbursement and clinical outcomes as valuable results.

How can we determine if our new EHR is earning its keep?

Every behavioral health organization has to track dollars, cents and hours, so at least in those areas you can use the EHR to monitor change and increase in value over time, even if pre-EHR tracking was less than judicious.

At the core, an ROI evaluation is still a costs-versus-benefits analysis. It’s just a little more complex with behavioral health IT. If you’re not yet working with some sort of tracking system and evaluation scheme, consider starting with a table of costs and benefits. Circulate the list to clinical, administrative and technical leaders and then update until all feel confident the table is comprehensive.

To get a more complete picture of actual value and return, the IoM model looks at three overarching components: expenses, benefits and potential impacts to revenue. Each category is divided up into numerous types in an effort to determine with specificity what is the value of a particular EHR investment.

“… benefits of robust information system implementation might include savings to an organization from the reduction or more effective deployment of full-time equivalents (FTEs) associated with more efficient business practices, decreased morbidity and mortality due to more consistently delivered, high-quality care, avoided complications from improved preventive care, and enhanced patient experience and outcomes through the opportunities afforded by EHRs and patient portals for engagement,” reads the IoM paper.

 It’s worth spending some time reviewing the IoM tables if you are questioning the value of your EHR or considering different solutions.

Can you afford a comprehensive EHR with reliable ROI without federal government help?

Absolutely.

There are many behavioral health EHRs out there with dramatic differences in both price and payment structure. Some acute care hospital EHRs also adapt well to the behavioral health environment. Yes, some of these systems are expensive and require substantial upfront expenditures for software licensing fees, infrastructure, consultants, network, etc. But other less expensive and robust options require almost no spending upfront if you have the infrastructure in place, and enable you to pay as you go via subscription.

Ultimately, much of the ROI for the healthcare IT system you choose is dependent on how you make it work for your behavioral health facility. Create organizational buy-in (especially among clinicians), evaluate workflows and how they might change to accommodate the EHR, and choose a solution that incorporates behavioral health-specific functionality and is a realistic financial fit.

Put the foundational pieces in place and the likelihood of positive ROI increases dramatically, even if that federal subsidy never materializes.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

Mental Health Needs Its Own Legislative Solution

Representative Tim Murphy’s Helping Families in Mental Health Crisis bill was approved by the House with near unanimity in early July. Among other objectives, the legislation seeks to expand the availability of psychiatric hospital beds, create a new assistant secretary for mental health and substance use disorders at the Department of Health and Human Services (HHS), and promote early treatment and intervention for young people who show signs of mental illness.

What this long overdue legislative recognition of the needs of the mentally ill does not seek to change is existing gun law or policy. Yes, earlier versions of Murphy’s bill generated opposition to some of the original details, as virtually all substantive legislation does, but an effective compromise was reached in part because these issues were still oriented around mental health care policy and funding. They had nothing to do with guns.

Now look at counterpart Senate legislation introduced by Chris Murphy (D-Conn) and Bill Cassidy (R-LA), which is identical to Helping Families in many ways. The Senate bill is stalled because of distracting attached language that seeks to overturn an existing VA policy that keeps veterans from possessing guns when they require a caretaker to manage their benefits. This diversionary addition significantly reduces the likelihood any meaningful mental health reform bill will emerge from Congress for the president to sign.

Here’s the thing we all should have learned by now: Issues related to guns are simply too controversial and complex to expect that they can be resolved via several sentences in a bill focused on increasing funding for mental health. We have a mental health crisis and to hold up legislation for political purposes related to who can own a gun is just sad.

“The vast majority of people with mental health problems are no more likely to be violent than anyone else,” says HHS on the mentalhealth.gov website. “Most people with mental illness are not violent and only 3 to 5 percent of violent acts can be attributed to individuals living with a serious mental illness.”

When it comes to improving our mental health system, we should leave any mention of guns out. If politicians want to change existing gun laws or policies, then deal with those issues separately rather than holding up proper care for the mentally ill.

What’s at stake, when it comes to providing proper care to our mentally ill? Why is mental health legislation such a pressing need? Let’s revisit just five key issues that beleaguer the American mental healthcare system. (Read the entire list here from an earlier blog post).

  • A recent study says the nation's psychiatric bed total has fallen 17 percent since 2010 and now stands at 11.7 beds per 100,000 people, an average far below the rest of the developed world.
  • Annually, about 38,000 Americans take their own lives, and 90 percent of those suicides are related to a mental health issue, according to National Institute of Mental Health (NIMH) Director Thomas Insel.
  • According to Health Affairs, two-thirds of primary care physicians are unable to find a mental health professional to care for their patients after diagnosis.
  • Robert Glover, executive director of the National Association of State Mental Health Program Directors, says that from 2009 to 2012 the states cut roughly $5 billion in mental health services and eliminated about 4,500 public psychiatric beds.
  • Estimates by the Department of Housing and Urban Development show a total homeless population nationwide of 650,000. Homeless advocacy organizations suggest the total may be as high as 3.5 million.

It’s difficult to say that strictly defined mental illnesses like bipolar disorder and schizophrenia are occurring more frequently, given that so many factors could contribute to that perception. Still, studies show anxiety and depression are “markedly higher” among millennials now than they were in previous generations. Baby boomers show a disturbingly high rate of depression and suicide, and their longevity means that Alzheimer’s and other forms of dementia will become more common.

Certainly, the resources required to manage a diagnosed mental illness are often more than one family can bear, which is what motivated Representative Murphy to act and why the Senate must follow suit.

The vast majority of the mentally ill are your mothers, fathers, brothers, sisters and friends – people who post no legitimate threat to others. With the baby boomer phenomenon, many are elderly, isolated, depressed or plagued with dementia.

It’s not an overstatement to say that America is approaching a mental health crisis requiring pragmatic, results-driven healthcare solutions. It will be very difficult to referee the guns debate and pass meaningful mental health legislation at the same time. While we debate, our mentally ill citizens are not receiving the care they need. Given the profound need of these people—a need many aren’t lucid enough to even be aware of—it’s shameful for the Senate to attach an ideological issue to legislation clearly intended to alleviate suffering.

Senators, based on the numbers alone, many more Americans will die next year from complications of mental illness than will be killed by a gun brandished by someone with a mental illness. It’s not that both issues don’t deserve your attention and vigorous debate. But you can’t allow mental illness to devour people who need help today. Follow the pragmatic lead of your House colleagues.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Behavioral Health

How can we commit to better mental health care right now?

Restoring lost beds, expanding health IT incentives and rapidly embracing ACOs are steps forward in addressing America’s mental health crisis

Chances are good someone close to you is suffering from a mental health disorder right now. You may not know it. While paranoid schizophrenia is pretty obvious, major depression can be hidden during periodic interaction.

Chances are also good that you don't have the knowledge or resources to deal with an extended bout of mental illness suffered by a family member. This was a primary concern in the recent passage by the House of the Helping Families in Mental Health Crisis Act, which seeks to overhaul the American mental health care system and awaits companion Senate legislation.

"No longer will we discharge the mentally ill out of the emergency room to the family and say, ‘Good luck, take care of your loved one, we’ve done all the law will allow.’" said bill sponsor Tim Murphy (R-Penn.) after the bill was approved by a landslide 422-2 margin.

New laws that fund more treatment will be helpful, to be sure, but the Helping Families Act will probably be more initial salvo than decisive blow, given what the nation is up against when it comes to mental illness.

The Centers for Disease Control estimates that 25 percent of Americans have a mental illness, and almost 50 percent will face at least one mental health challenge at some point in their lives. The U.S. Department of Health and Human Services says 8 percent of Americans could benefit from drug or alcohol treatment.

These are eye-opening figures that most outside the mental health community probably don’t know about. Here are some more.

  • A recent study says the nation's psychiatric bed total has fallen 17 percent since 2010 and now stands at 11.7 beds per 100,000 people, an average far below the rest of the developed world.
  • Annually, about 38,000 Americans take their own lives, and 90 percent of those suicides are related to a mental health issue, according to National Institute of Mental Health (NIMH) Director Thomas Insel.
  • According to Health Affairs, two-thirds of primary care physicians are unable to find a mental health professional to care for their patients after diagnosis.
  • Robert Glover, executive director of the National Association of State Mental Health Program Directors, says that from 2009 to 2012 the states cut roughly $5 billion in mental health services and eliminated about 4,500 public psychiatric beds.
  • Estimates by the Department of Housing and Urban Development show a total homeless population nationwide of 650,000. Homeless advocacy organizations suggest the total may be as high as 3.5 million.
  • 2012 survey by the Substance Abuse and Mental Health Services Administration (SAMHSA) showed that almost 40 percent of adults with severe mental illnesses (schizophrenia, bipolar disorder) received no treatment in the previous year; among those with any kind of mental illness, 60 percent went untreated.
  • The largest mental health facility in America is Chicago’s Cook County Jail, where, according to a recent Atlantic article, officials estimate as many as 33 percent of inmates have some kind of mental illness.
  • Estimates suggest as many as 590,000 people annually end up in America’s de facto mental health system: jails and prisons, streets and homeless shelters, the morgue.
  • According to Insel and NIMH research, mental illness costs America about $444 billion a year, with a third of that going to medical care and the majority to disability payments and lost productivity.

We all tend to walk around the homeless in big cities because we don’t know what to do, but these anecdotal experiences also tell a tale. The chronically homeless, those who don’t show up at shelters and soup kitchens to be counted, have completely fallen through the societal cracks. They are apparitions on corners and in doorways, like Dickensian ghosts sending a message we don’t much care for.

I could add more bullet points to this list above, but you get the idea. And, no, I am not suggesting the solution to each of these problems is the same. I am suggesting that the solution is to treat mental health as one component in overall health and start to develop a legitimate mental health system. It can happen on the state level, but those states need to share data or we end up with silos and ineffectiveness.

And the federal government must get involved or there simply is not enough money to make this happen. The feds are certainly aware of America’s converging mental health challenges, but in many ways they seem more interested in measuring than addressing them. Greater scrutiny of records and treatment plans is becoming the norm with regard to Medicare and Medicaid, putting strain on fractured and mostly paper-based inpatient mental health facilities.

So, what can we do right now to start to grapple with America’s looming mental health crisis?

  1. Restore the psychiatric beds lost during the economic downturn: Most states cut budgets during the recent recession, which hit mental health facilities particularly hard. Tax revenues are starting to tick up, but the federal government will probably have to get involved through block grants or other incentives to bring the beds back online. This effort must be coordinated with local law enforcement so we lessen the number of disturbed people in jails and instead send them to a place where they can get treatment.
  2. Push the Accountable Care Organization model: Currently, ACOs are happening through the Affordable Care Act. In the event the ACA goes away, the idea behind ACOs should be pursued by other means. Because ACOs are responsible for the entire patient, not just that deep cut or broken finger, there is a pathway for treatment of mental health and addiction challenges. This is the future model for American healthcare, and we’re not getting there fast enough.  
  3. Expand health IT incentives to mental health care: Reporting requirements for mental health facilities are getting more stringent, and yet most are still managing with paper records. Without Medicare and Medicaid reimbursement, many mental health and addiction facilities will go under, leaving even fewer beds available. If we believe that computers are a benefit with physical and surgical care, then they are also a benefit with mental health care.  
  4. Make parity work: Yes, federal legislation requires that insurance companies cover mental health on par with physical health IF the policy includes it. But parity legislation has not achieved its goals because there is no agreed upon definitions of adequate mental health care between insurance companies and caregivers. There is also the question of whether or not insurance should include mental health care. If almost half the country will need the care in a lifetime, why are we excluding it? 
  5. Build public transitional housing: Cities are finding that building apartments and staffing them with nurses is cheaper than rolling out emergency services every time a homeless person requires care. The chronically homeless—those with debilitating illnesses like bipolar disorder and schizophrenia—can be treated and monitored in an apartment complex.
  6. Outreach, outreach, outreach: The military and VA are working to locate, educate and treat veterans, but it’s not nearly enough. Only 72 percent of Iraq and Afghanistan veterans were employed in 2013, according to government statistics, exacerbating the tendency to drink. Public service campaigns encouraging corporations to give to mental health organizations would also be helpful. Billions go into cancer research every year, and a fraction of that is donated to mental health, despite the crippling impact on productivity mental illness has.

What none of these efforts alone can do is remove the stigma of mental illness—the myth that instability is manifest weakness. Government and corporations can help with focus and funding embodied in efforts like the Helping Families in Mental Health Crisis Act, but they cannot engineer a more compassionate, understanding society. That part starts with each of us as individuals making choices.

However, if we, as a society, can succeed in treating the mentally ill, the stigma can disappear all by itself because we will have overcome the mental health challenge. Our fellow citizens are depending on us.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Behavioral Health

Shouldn’t we have a Human Genome Project for mental illness as well?

Success in understanding, treating and preventing specific diseases has often resulted from concentrated research initiatives backed by strong sponsors and robust funding.  

A great example: the extraordinary 13-year long national Human Genome Project (HGP) that not only achieved its goal of mapping the genes in human DNA, but also unearthed the genetic roots of many diseases. Jointly undertaken in 1990 by the Department of Energy and the National Institute of Health, with a total cost of $3.8 billion, the Project sequenced about 90 percent of the human genome, with 99.9 percent accuracy. There are about 20,500 genes in human DNA, made up of about 3 billion chemical base pairs (DNA building blocks), according to the National Human Genome Research Institute.  The DNA sequence database has been made widely available, and has fostered continuing research into prevention and treatment of specific genetically related diseases.

 Benefits of the HGP

  • Understanding the genetic “blueprint for human life” has enabled scientists to pinpoint more than 1800 genes tied to common diseases such as diabetes, breast cancer, muscular dystrophy and Parkinson’s disease, and undertake more educated research into prevention and treatment.
  • More than 2000 genetic tests have already been developed for human conditions, enabling patients and their doctors to understand genetic risks for disease.
  • Knowledge of the variation of DNA and its effects is revolutionizing drug development and modification.
  • The White House reported economic output of the HGP at approximately $796 billion (about $141 for every dollar invested).

Legacy of the HGP

  • While the list of disease-related answers provided by genomic analyses is growing, much research on complex diseases such as heart disease continues.
  • Exciting new work is underway to enable increasingly productive implementation of genomics in clinical care.

Indeed, science may have reached a point where additional energy and funding might yield even more healthcare-related advances, including breakthroughs in understanding and treating mental illness. The HGP has helped us discover genetic roots of many physical diseases and some mental illnesses, such as autism, ADHD, bipolar disorder, major depression and schizophrenia. But there is much to be done to better understand, manage and even cure mental illnesses.

If the time, energy and money on HGP has yielded so many benefits, can’t we invest more money and effort into mental healthcare?

The Soaring Costs of Mental Illness

As Charles Roehrig of the Center for Sustainable Health Spending at Altarum Institute in Michigan spelled out in a recent Health Affairs study, mental disorders are easily the most expensive medical condition in the American healthcare system, exceeding $200 billion annually for the most recent year (2013) in which data was available. Rounding out the top four are heart conditions ($147 billion), trauma ($143 billion) and cancer ($122 billion).

The contrast between attention and impact leaves many confused.

"Is there the kind of concerted effort (for suicide) that's been made with HIV, with breast cancer, with Alzheimer's disease, with prostate cancer?" Christine Moutier, chief medical officer for the American Foundation for Suicide Prevention, asked in a far-reaching USA Today series on mental illness. "There's never been that kind of concerted front."

No, there has not, even as mental illness spending has risen to the top of the table.

Roehrig tracks both the raw-dollar cost of each broad medical condition and the annual rate of growth. The growth rate in costs for both high cholesterol and heart conditions, for example, fell to 2 percent between 2004 and 2013 after the introduction of new pharmaceuticals and treatment methods.

In contrast, mental illness spending grew 5.6 percent from 2004-2013, which was less than several other medical conditions but still impactful because it’s the largest spending category and contributes the most in terms of excess dollars spent.  

Our Inadequate Investment in Treating Mental Illness

Now, compare the growth in the costs of mental illness to actual spending on efforts to treat it.

“In the past two decades, mental health services have been shrinking, not growing,” wrote the Bloomberg News editorial board in a recent op-ed. “From 1992 to 2012, the number of psychiatric beds per capita fell by two-thirds, to just two for every 10,000 people. The U.S. is the only affluent country where the number of psychiatrists per capita fell from 2000 to 2011, even as it spends twice as much as others on health care.”

“When more than half of people who need mental health care can’t or don’t get it—as is true in the U.S.—other problems arise,” writes Bloomberg. “For sufferers, these include physical illness, lost earnings, substance abuse and suicide. For society, there is greater crime and homelessness.”

According to NAMI estimates:

  • Roughly 26 percent of homeless adults staying in shelters live with serious mental illness; 46 percent live with severe mental illness and/or substance use disorders.
  • About 20 percent of state prisoners have a mental illness in their recent history.
  • Among youth in the juvenile justice system, 70 percent have at least one mental health condition.
  • Only 41 percent of adults in the U.S. get the mental health care they need.
  • Adults with mental illness die 25 years earlier than others, on average, mostly from treatable conditions.
  • More than one-third of students with a mental illness drop out of school.

What NAMI also tells us is that half of all mental illness begins by age 14, and two-thirds by age 24. There are opportunities to identify mental illness early and intervene with awareness, medication and support.

Indeed, there is already evidence that schizophrenia, for one, can be managed and treated. "If you can get at it early enough, before it becomes too severe, there is a very good chance that the person will recover, which is just very, very exciting," Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors, told USA Today.

Frustratingly, mental illness is a medical and sociological contradiction, both common—roughly 25 percent of the population deals with some kind of mental health challenge in a lifetime—and elusive in terms of diagnosis and treatment. Unfortunately, the future will only be more challenging.

“A look ahead suggests that reductions in deaths from heart conditions and cerebrovascular disease are likely to drive spending on mental disorders even higher, as more people survive to older ages,” Roehrig writes, “when mental disorders, such as dementia, become more prevalent.”

The solutions to America’s mental health issues must be near term and include major investment in concerted research on causes and treatments. But that’s not all. We have to alter the healthcare system to integrate acute and behavioral health services. We need to integrate computer systems so ER physicians have access to complete records and know when to call in psychiatric assistance. And we need to apply Meaningful Use or its equivalent to behavioral health so that all healthcare providers’ information technology will function at the same high level, enabling gathering and aggregation of widespread data for better analyses and solutions.  

The NIH described the Human Genome Project as biology's equivalent to "the Apollo moon shot." Can America afford a mental health equivalent? I’ll argue that we must. Since we’re spending the money anyway, it’s a moral imperative to do so in a way that actually helps individuals suffering with mental illness and significantly improves our overall population health.

Category: Behavioral Health

No federal health IT support? No problem.

How three behavioral health hospitals made the leap from paper to EHRs without financial assistance

For behavioral health hospitals that don’t yet have an EHR and think they can’t afford one without financial assistance, the wait for federal government support continues.

But it doesn’t have to. In this detailed case study, three inpatient behavioral health facilities entered the EHR era by selecting OpenVista, a comprehensive clinical and financial solution available through a subscription service, negating the huge upfront costs so common to EHR acquisition.

While affordability was essential to EHR acquisition, it was the improvements on patient care and clinical efficiency that made OpenVista a valuable investment. Overnight, clinicians and staff enjoyed better record keeping and reporting, rapid access to patient records, and integrated and improved patient care.

Click to visit the Resource Center and download this recently released case study and find out how OpenVista is enabling better behavioral health care without federal subsidies.

Category: Behavioral Health

Is telemedicine the key to making addiction treatment work?

In a world where only the wealthy suffered from addiction, we wouldn’t have to worry so much about the effectiveness of treatment or who was going to pay for it.

But most people don’t live in Malibu or have access to Betty Ford, so efficacy matters.

Especially to insurance organizations, including the federal government, which have become increasingly more hesitant in recent years to pay for inpatient addiction treatment when it seems no one can demonstrate what actually works.

“Substance abuse providers generally have insufficient data to demonstrate the effectiveness of their treatments,” writes Health Data Management reporter Joe Goedert. “As a result, insurers are becoming highly distrustful of addiction treatment; and reimbursement amounts are falling as payers start to move to value-based contracting.”

The use of telehealth and telemedicine to track the effectiveness of treatment among those plagued by addiction is only the most recent trend in remote patient care. According to the American Telemedicine Association, about half of all states have passed laws mandating coverage by insurers of telemedical services. The legislation could prove useful to insurance companies and CMS if telemedicine provides better data on what works in treating addiction.

Map Health Management, a data analytics firm focused on behavioral health and addiction treatment, is working with insurers to determine effective treatment modalities and identify care providers that effectively maintain a relationship with patients after they leave the hospital. Telehealth / telemedicine offers a tool that both enables these efforts and makes them cost effective.

According to Map Health Management CEO Jacob Levenson, the effective use of telehealth technologies may be so important to effective addition treatment in the future that they become the dividing line between failure and success for providers.

“Some 30 percent to 40 percent of providers may not be in business within five years because they can’t adapt,” Levenson told Health Data Management.

Telehealth is one component in an innovative opioid treatment research project being conducted in Washington, DC. In a departure from the norm, the program is oriented around the practice of Edwin Chapman, MD, in partnership with Howard University’s Urban Health Initiative.

In this impoverished corner of the nation’s capital, Dr. Chapman’s patients in the study average 52 years of age and 10 years of incarceration. About 60 percent live with hepatitis C, 10 percent are HIV positive and all are long-term users of opioids, primarily heroin.

Chapman’s experience showed him that the opioid replacement buprenorphine effectively stabilized his patients’ addiction issues enough that they could face other life challenges so long as they had access to comprehensive care, including psychiatric services. While access to the opioid replacement was available, care and counseling were not.

So Chapman and Howard Professor Chiledum Ahaghotu, M.D., worked together to create the Buprenorphine Integrated Care Delivery Project model.

“I was looking to improve care for vulnerable populations, and to avoid an overutilization of [high-cost] resources,” such as emergency care, says Ahaghotu.

Thus, the project incorporates three essential components:

  • Comprehensive care coordinators work closely with both primary care and behavioral health providers to help develop patient-centered care plans.
  • A shared electronic health record platform across all providers delivers services to the patient. Patients consent to share their health data with various providers.
  • A telehealth program allows Chapman's patients to see him as well as a behavioral health specialist during the same office visit.

The entire project is funded by a four-year grant from Washington, DC’s, department of health and aims to reduce the cost of addiction treatment, which generally costs Medicaid roughly five times that of a typical Medicaid patient.

If the DC project and others like it prove effective in reducing incidences of drug relapse and lowering costs of treatment, you can be sure that the federal government and private insurers will notice and implement policies aligned with what works. Evidence suggests telehealth and telemedicine solutions will be a part of that overall solution. 

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

How do we balance civil liberties with treatment of the mentally ill?

In January of this year, political analyst Norman Ornstein lost his 34-year-old son, Matthew, to accidental carbon monoxide poisoning. While Matthew’s death was a tragic blow to family and friends, it was not the kind of out-of-the-blue shock that comes with absolutely no forewarning. Matthew, as Ornstein says in a New York Times op-ed published last month, had struggled with mental illness for 10 years, which contributed to poor decision making and his untimely death.

A resident scholar with the American Enterprise Institute and writer for The Atlantic and Washington Post, Ornstein says that perhaps the most difficult aspect of Matthew’s death was the inability of family and friends to help treat Matthew’s mental health challenges after he had his initial psychotic break.

“Whatever his illness … Matthew was particularly afflicted by one component of his illness: anosognosia, the inability of a person to recognize that he or she is ill,” Ornstein writes. “Since Matthew was over 18, neither family members nor professionals had any legal authority to get him treatment for the symptoms that kept him from living a stable life.”

Having a mentally ill child, as Ornstein describes, means living in constant fear the child will be injured or killed by police who are unaware of or misunderstand his condition. It also spawns semi-desperate visions of what Ornstein calls a “happy ending”—peaceful arrest followed by a compassionate judge mandating assisted outpatient treatment.

Matthew did not see himself as sick and was not perceived as a threat to himself or others, so there could be no happy ending.

There are, as a resident of or visitor to any American metropolis knows, millions of Matthews out there. According to the Treatment Advocacy Center, the U.S. has 3.9 million U.S. adults with untreated severe mental illness in any given year (1.2 percent of the population).

“The true insanity is that our laws leave those who suffer to fend for themselves,” Ornstein says.

Representatives Tim Murphy (R-PA), the House’s only clinical psychologist, and Eddie Bernice Johnson (D-TX), a psychiatric nurse, are sponsoring legislation with the goal of patching some holes in America’s mental health system, notably by expanding assisted outpatient treatment (AOT).

“The specifics of A.O.T. vary by state, but judges can order patients to undergo treatment while they live in the community instead of in prison or a hospital,” Ornstein writes in support of both the Murphy-Johnson bill and AOT. “It has been proven to reduce crime by or against those with illnesses, as well as suicide … In many states, families can petition the court directly based on the likelihood that their loved one has a grave disability or condition.”

As with all things mental health, the devil is in the detailed application of legislation and policy. No, AOT is not universally embraced. One need look no further than the responses to Ornstein’s op-ed to find those who respectfully disagree with his promotion of the strategy.

“The Murphy Bill is driven by fear and a poor read of the best evidence on what is helpful for people who experience psychiatric struggles,” writes Kendall (no last name given), a social worker from New York. “It dismantles [the Substance Abuse and Mental Health Services Administration] in its current form. It violates the civil liberties of those diagnosed with a psychiatric disorder without cause (it really should be IOT not AOT - it is involuntary not assisted).”

In many ways, the civil liberties concern Kendall mentions is the crux of this issue, so I want to be clear: I am not advocating the violation of anyone’s civil liberties. Legislation must be drawn up and put into practice with great care and deliberation.

But I think we must also question how and what civil liberties are appropriate for the mentally ill. How high a priority is self-determination for people effectively locked up in their mental illnesses?

As reported in a New York Times story on a controversial New York State law, Michael and Barbara Biasotti watched their mentally ill daughter in her 20s cycle in and out of hospitals and treatment programs while engaging in all kinds of other risky and dangerous behavior. The Bisasottis got a court order compelling treatment under what’s called Kendra’s Law, so named for a woman who was pushed onto New York City subway tracks in 1999 by a schizophrenic man.

“I really don’t think she would be alive” without it, Barbara Biasotti told the Times. “And we don’t know if she would have taken a couple of people with her.”

Living in San Francisco, I see dozens of people each week like the Biasottis’ daughter. Some are lucid and conversational; many are clearly unable to provide for their own needs. Should my concern be for the civil liberties of these individuals, my fellow citizens? Or should my empathy be for other human beings plagued by a sickness for which they are incapable of seeking help? Can I find a balance between the two?

It is important to recognize that those who argue on behalf of civil liberties make a noble and worthwhile point.  But we are faced with a scenario in which the mental health system is broken to such an extent that inaction is not an acceptable response.

Action in the form of early intervention probably saved the life of Tiffany Martinez when she started to experience symptoms as a college student of the same schizophrenia her father suffered. Early intervention programs surround the patient with enough support and counseling to turn a debilitating disease into a manageable condition.

"If you can get at [mental illness] early enough, before it becomes too severe, there is a very good chance that the person will recover, which is just very, very exciting," Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors, told USA Today.

But how do we get to the not dangerously ill early without some kind of compelling event, especially when they are adults and courts can’t or won’t act on the experiences of family?

“Here is the Kafkaesque irony: Far from respecting civil liberties, legal obstacles to treatment limit or destroy the liberty of the person,” wrote author and consultant Herschel Hardin in 1993. In addition to serving on the board for Canada’s Civil Liberties Association and working with Amnesty International, Hardin had a schizophrenic child. “Medication can free victims from their illness—free them from the Bastille of their psychosis—and restore their dignity, their free will and the meaningful exercise of their liberties.”

Of course, AOT is only one component of the Murphy-Johnson legislation, even as it is probably the most controversial. Earlier versions of the bill included provisions for expanding federal subsidy of electronic health record purchase by mental health facilities. Those sections were stripped out in committee, leaving hospitals and clinics to fend for themselves in acquiring the kind of technology that enables ER docs to know immediately when someone with a mental illness walks through their doors.

Perhaps expanded AOT and early intervention could have saved Matthew Ornstein, or perhaps it can save the next troubled son or daughter. Some kind of compelled treatment may have been the unmet holiday wish of the Ornsteins last season. So this Christmas, it is my wish that Congress act in some way to stem the tide of untreated mental illness in America.

While not perfect, the Murphy-Johnson bill is the most significant mental health legislation considered by Congress in decades. It has the potential to make Christmas 2016 much brighter for some family that this year is desperate for help. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

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