Out of the School

Behavioral health facilities seek to be included in meaningful use incentive payments.

The Health Information Technology Extension for Behavioral Health Services Act, currently in committee, would extend federal incentive payments for HIT adoption to previously ineligible behavioral health care providers and facilities. In addition, it would expand the list of eligible professionals to include clinical social workers and clinical psychologists. Currently, behavioral health care provider organizations can qualify for Medicare and Medicaid incentive funds only through the existing definition of eligible professionals, which includes physicians and nurse practitioners affiliated with their facilities.

Despite being ineligible for large incentives intended to encourage the deployment and meaningful use of EHRs, approximately 20% of behavioral health organizations have already implemented electronic records technology, according to member surveys conducted by the National Council for Community Behavioral Healthcare. Many more would like to purchase EHRs but simply can’t afford them, says Chuck Ingoglia, MSW, the council’s vice president of public policy.

“Community mental health and addiction organizations recognize the benefits of electronic health records,” he says. “However, operating margins for most mental health organizations are very slim and don’t leave any capital to invest in infrastructure improvements like EHRs.”

“Although nationwide the figures for EHR adoption in behavioral health are about the same as for the healthcare industry as a whole, implementation is likely to remain stagnant without stimulus incentives because many of these organizations struggle just to meet their overhead,” says e-health consultant Jim Tate. “While psychiatrists and even chiropractors are eligible for the meaningful use incentives, behavioral health was among the disciplines that lost out. I’m hoping that the legislation currently in committee will correct that omission, but I’m not holding my breath.”

That raises the question of why these facilities were left out in the first place. “When President Obama first announced the incentives, it was going to be a $50 billion initiative,” says Ingoglia. “Then it shrunk to $20 billion and committee staff were left with the challenge of prioritizing the available resources. They decided that general hospitals and providers would be a good place to start, with the hope that additional entities could be brought online with future investments. General hospitals that have psychiatric departments are included, but freestanding psychiatric hospitals and rehab hospitals are ineligible.”

Tate suggests the omission occurred because the committee adopted the definition of an eligible provider from Medicare’s fee-for-service system. “Behavioral health, with the exception of psychiatrists, has never been Medicare fee for service,” he says.

In addition to scarce resources, another barrier to EHR adoption in behavioral health and related settings is that most systems are not designed for these facilities. “The large players in the general medical EHR space don’t tend to have a robust behavioral component to their record,” says Ingoglia. “However, a number of specialty vendors have emerged that market specifically to behavioral health providers and are working hard to meet the evolving meaningful use requirements and functionality needs of behavioral health.”

“Most EHRs are designed for the information needs and workflow of a traditional physician-based practice,” says Laura Fochtmann, MD, chair of the American Psychiatric Association’s Committee on Electronic Health Records. “Clinics that provide mental health, behavioral health, and substance abuse treatment typically have a very different model that is multidisciplinary and involves communication and coordination of care, with each professional having relatively independent functions. Such settings also have different requirements for documentation (eg, detailed multidisciplinary treatment plans) and a need to be able to document treatments such as group therapy. Further, electronic records designed around the collection of structured data (eg, check-box approaches) are not well suited to capture the individualized nature of patient feelings and experiences, which are integral to mental health treatment.”

While it’s possible to capture such information via text entry or dictation (including voice recognition), that’s a time-consuming effort, says Fochtmann. Relying on voice recognition alone makes it difficult to leverage the pluses of electronic records whereas using a mix of text and structured data entry doesn’t mesh well with typical workflows and impedes productivity.

Tate believes there are plenty of behavioral health-specific EHRs to choose from and cautions facilities not to deploy software that has been developed for a general hospital or primary care practice. On the other hand, some EHRs designed specifically for behavioral health settings don’t incorporate medication administration and prescribing, which some but not all of these settings need, according to Fochtmann. Tate recommends getting advice from similar clinics or mental health environments that have implemented EHRs or contacting behavioral health associations for information regarding HIT adoption.

Privacy concerns present another barrier to EHR adoption. “For substance abuse treatment settings, federal regulations for release of information are more stringent than HIPAA,” says Fochtmann. “The same is true for release of mental health information in some states. Independent of these regulations, patient concerns about the confidentiality of their information are common and vary from individual to individual. Unless electronic record products are designed with the flexibility to give patients choices about the sharing of their information, patients and mental health professionals are likely to be wary of electronic records. At the same time, the sharing of information to enhance care (eg, in emergencies, among professionals treating a patient) is an essential ingredient of optimal care.”

Silver Hill Hospital and Manatee Glens are among the organizations that have overcome these barriers, identified effective EHR technologies, and implemented them successfully.

Proven and Affordable

Located in New Canaan, Conn., Silver Hill uses the OpenVista EHR, a commercialized version of the VA’s VistA EHR system that is available to anyone through the Freedom of Information Act. Widely credited with helping transform the VA into an efficient and clinically effective healthcare organization, VistA played a key role in inspiring the current multibillion-dollar federal stimulus initiative to motivate U.S. healthcare providers to achieve meaningful use. Enhanced for commercial healthcare and made available as open source by Medsphere Systems Corporation, OpenVista is a portfolio of products and professional services for hospitals, clinics, and integrated delivery networks.

“Our OpenVista application includes computerized physician order entry, medication order management, and bar-code medication administration,” explains Sigurd Ackerman, MD, Silver Hill’s president and medical director. “Most importantly, OpenVista’s open source architecture allows us to tailor the application to facilitate suicide assessments, multidisciplinary treatment plans, and other custom requirements. The VA system has been around for 20-plus years and is very robust but like any psychiatric facility we needed certain add-ons. For example, many of our patients require detoxification from alcohol and other substances, and we have to record vital signs and symptoms of withdrawal every couple of hours to adjust medication. We needed an EHR that could array, calculate, and display cumulative results over several days for anyone caring for the patient.”

Via OpenVista’s collaborative HIT platform, the hospital shares clinical insights with other mental health care providers. “For example, when we develop a multidisciplinary treatment plan in collaboration with Medsphere, it becomes available to any hospital that uses OpenVista,” says Ackerman. Last fall, the hospital shared the products it had designed via the Healthcare Open Source Ecosystem, a global community of clinicians, administrators, software developers, and enthusiasts. The hospital’s ecosystem contributions include psychosocial assessments, a suicide assessment scale, a CAGE (an acronym for four standard alcoholism screening questions) questionnaire and mental status assessment, nursing assessments with detailed substance and psychiatric history components, and diagnosis-specific treatment plans.

One advantage for budget-constrained facilities is Medsphere’s subscription-based pricing that allows hospitals, clinics, and integrated delivery networks to pay for OpenVista without any up-front investment. “Open source software is very affordable,” says Ackerman. “The OpenVista solution is free, actually, and Medsphere bills only for implementation, training, and support. Quarterly payments are spread over five years.”

Because Silver Hill had another EHR prior to OpenVista, staff was already trained on computer use. Still, it was necessary to “sell” people on the need for a new system.

“Staff acceptance and training take more time, effort, and money than most people anticipate,” says Ackerman. “We decided on a go-live date when we stopped using the old system and brought in the entire new system. The preparation is huge for this kind of thing.”

Meeting Business Process Needs

Manatee Glens, located near Tampa Bay on Florida’s west coast, is a nonprofit behavioral health hospital and outpatient practice that chose Netsmart Technologies’ Avatar, a specialty behavioral health EHR, after a thorough due diligence process.

“We previewed about 15 different systems,” says President and CEO Mary Ruiz, MBA. “We started with webinars, narrowed them down to five for on-site demonstrations, and then visited three installations. Myself and my CFO [chief financial officer] then met with the senior management teams of the two top-ranked companies. We viewed their strategic plan and financials because we were looking for a technology partner that was well capitalized and had a business model that would see them through turbulent, fast-changing markets. We also had to make sure they had a vision of the future that included us as one of their central customers. There is no perfect software out there. Every system has its strengths and weaknesses, and you have to find a match that works the best with what you’re trying to accomplish.”

While Manatee Glens searched for technology that was designed for behavioral health, Ruiz was not looking for software that was customizable. “Our goal was to find a software that met our business process needs and one to which we could match our processes,” she says. “We’re in the behavioral health business, not the software business. The functionality we needed included scheduling, assessments, treatment plans, progress notes, electronic prescribing, and order entry. The problem with customization is that every time your vendor comes out with a new module or upgrade, you have to reimplement and recustomize it. Scalability, on the other hand, was essential because we wanted to make sure the software would be able to keep up with our growth.”

Manatee Glens generated buy-in by introducing technology gradually over time. “Our doctors used e-prescribing for years before we gave them the complete electronic record,” says Ruiz. “Our staff became hooked on computer use with Microsoft SharePoint desktop functionality for collaborating on documents, meeting online, and uploading departmental information and reference tools.”

Manatee Glens implemented the Avatar EHR in its outpatient facilities in April 2009 and in its inpatient and residential facilities in April 2010, followed by e-prescribing. “Our gradual, well-planned-out implementation helped build our staff’s confidence,” says Ruiz. “Sometimes EHR implementations fail because organizations are attempting to make their workers dependent on computers for the first time.”

Another success factor at Manatee Glens was creating a cross-disciplinary team that spent one year planning the implementation. The organization also beefed up its IT capabilities and staffing.

Ruiz recommends investing in technical consultation from the EHR vendor. “You can’t expect your vendor to implement it for you, but you have to buy the expertise for the implementation. That’s absolutely critical. Do not short your budget in that area because you’ll pay for it year after year,” she says.

Meeting the available federal incentives is a priority at Manatee Glens. “While behavioral health facilities were eliminated from the large stimulus incentives, significant Medicaid incentives are available at the physician level for meeting meaningful use criteria,” says Ruiz. “Over a multiyear period, we expect to be eligible for $50,000 to $60,000 per prescriber. That’s well worth the effort of demonstrating meaningful use. In fact, meaningful use is our focus for the future in terms of our continued EHR implementation. Meeting the criteria is doable, but if you wait until the last minute, it’s not.”

To demonstrate its desire to meet meaningful use criteria, Manatee Glens borrowed much of the money it needed to implement its EHR. “We borrowed against our future. It was that important to us,” Ruiz says.

It Pays to Be Hopeful

For behavioral health facilities anxious to be included in the incentive bonanza, the next few months will be key. “The House bill was introduced in April,” says Tate. “Within a few weeks it was sent to committee and has been there ever since. The Senate bill was introduced in August and also sits in committee. I doubt anything is going to change between now and January, when the program begins. The vast majority of bills die in committee.”

Nevertheless, Ingoglia is hopeful. “We have considerable support from our members, who understand that we need to be part of the larger healthcare system and able to share information with the larger healthcare systems to improve outcomes,” he says. “We’ve been very encouraged by the bipartisan support the idea has generated. We have 79 cosponsors in the House. Sen Snowe from Maine just became the first Republican cosponsor of the Senate bill, which was introduced much more recently, and we have eight Democrats supporting that bill. That’s very exciting. In this business, it pays to be hopeful.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.

Click on For The Record to read Alice Shepherd's original article.