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Coordinated Care and EHRs: Where Does Behavioral Health Fit In?

laptop and stethoscope

Behavioral health presents EHR challenges. Photo via flickr.

One of the goals of the Affordable Care Act is to drive coordinated care delivery. But including behavioral health as part of the overall patient story has been a sticking point for many technologists and physicians. It presents some challenges – but those challenges are far from insurmountable.

For hundreds of years, many patients treated with behavioral medicine were considered disabled. They lived in a hospital setting, says Jacob Buckley-Fortin, president of Boston-based eHana, which provides a web-based EHR for behavioral health and human service organizations.

It wasn’t until the 1970s that the mental health care system transitioned to a community-based service model for patients who needed psychiatric and other behavioral health services. And Buckley-Fortin notes that while this transition has been largely successful, incorporating the needs of behavioral health in a segmented American healthcare system is an ongoing challenge.

One difficulty is that behavioral health has its own workflow processes which grew in parallel to the general medicine system. Many patients served by behavioral medicine also have other daily challenges which range from substance abuse to legal issues to housing – all of which need to be documented to provide real context on a patient.

Behavioral health clinicians have a tough job, then, says Buckley-Fortin – and he would know, as the son of two social workers. Therapists and social workers – many of whom work on a fee-for-service basis – are time constrained and need an easy-to-use EHR that doesn’t require a lot of work to get the data in and out. This is part of the reason why complicated interfaces aren’t a good fit for the social workers, psychiatrists and addiction specialists inputting data into an EHR.

Both Buckley-Fortin and Dr. Arshya Vahabzadeh, a resident physician in child and adolescent psychiatry at Massachusetts General Hospital, McLean Hospital and Harvard Medical School, agree that a mindful approach must be taken when determining the appropriate level of information captured in an EHR.

Dr. Vahabzadeh notes that in behavioral health, the physician-patient interaction is captured primarily in longer narrative form – so paragraphs, rather than the “check boxes” you find in the typical EHR. That matters for individual patient encounters, but it’s also important when it comes to analyzing data within an EHR. What’s needed are best practices for clinicians documenting care provided during one-on-one therapy and group therapy sessions, he says.

There’s also the issue of notes taken by therapists during their private consultations with patients – and whether it’s appropriate to include the full details of those conversations in the EHR, says Dr. Vahabzadeh. He says it comes down to how much privacy a patient expects when they’re talking to a clinician. For example, a wife speaking with a therapist about her marital problems probably doesn’t want to have her deepest feelings about her husband revealed in her electronic medical record.

Largely, the problem of developing an effective behavioral health EHR strategy is also about financial incentives. According to the National Council for Behavioral Health, mental health and addiction providers experience significant financial hardship when trying to adopt comprehensive EHR systems, and fewer than 30% have been able to implement full or partial systems.

There’s a very high incidence of cancer, heart disease, diabetes and asthma among the more than 6 million Americans served by the public mental health and addiction treatment system, according to a study by the Center for Behavioral Health Statistics and Quality. Despite this, many behavioral health organizations aren’t eligible for Meaningful Use incentives.

When therapists and social workers don’t qualify for Meaningful Use funds, it means that a community-based mental health facility with 300 staff members would largely be ineligible for incentive funding, since it has only five psychiatrists practicing at that site. This reality has “significantly hampered overall adoption amongst behavioral health providers,” says Buckley-Fortin.

Another hurdle is data collection, which is focused on the typical physical health workflow that requires vitals and immunizations – much of which is irrelevant for the psychiatrist, depending on their specialty.

Undaunted, Buckley-Fortin points to legislation endorsed by the National Council for Behavioral Health that would allow community mental health centers to register for incentive funds on an institutional level rather than through their eligible professionals.

So is it all dark waters and challenges ahead for behavioral health EHRs? Not quite. Although behavioral health documentation is difficult to analyze across patient populations, there are metrics that can be measured, such as depression or anxiety scales, says Dr. Vahabzadeh. He notes that there are tremendous benefits for integrating behavioral health into the overall healthcare system.

Coordinated care is where healthcare is going, he says. That means that the integration of behavioral health into existing EHRs is necessary. “There are challenges, but we’re not going to be in a position where we can give up. We have to be problem solvers going forward,” he notes.

And while Buckley-Fortin says we’re at a “stark transition point,” he is passionate about the need for increased collaboration, more evidence-based medicine and care coordination across the healthcare system. He’s also confident that financial incentives directed at behavioral medicine will drive further technology investment and have a dramatic impact on coordinated care.

Aine Cryts

Aine Cryts

    Aine (“ONya”) Cryts is an on-staff contributing writer for MedTech Boston. She's a political scientist by education, a writer and marketer by trade. She has written for various healthcare technology publications and also served as marketing director at several healthcare software companies in the Boston area. Cryts is an avid volunteer, pet lover and long-distance runner. Story ideas are always welcome.

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