By Kaye Eisele, EHR Institute

Behavioral health records contain highly confidential patient information, much of which is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. The state of electronic health records (EHR) as they relate to HIPAA compliance is particularly concerning when looking at converting paper health records to EHR. While many therapists and psychiatrists have long since acquainted themselves with EHR and many acknowledge the benefits they provide, just as many foresee difficulties with EHR pertaining to patient confidentiality.

Robert Plovnick, M.D., M.S., and Director of the Department of Quality Improvement and Psychiatric Services at the American Psychiatric Association (APA), noted his concerns when he addressed the House Small Business Committee in July 2008.

“Electronic health information exchange could erode patient trust and impede clinical care if it facilitates dissemination of sensitive information without sufficient precautions being taken to protect privacy,” he said. “Second, a significant percentage of APA members operate in solo, private practices in which the up front costs of implementing a health IT [information technology] or EHR system present a considerable barrier to adoption.”

Dr. Plovnick has ample reason to be concerned. While many of the larger behavioral healthcare agencies have designated information technology staff, solo providers or small private practices may find difficulty in converting from paper to EHR. Many of the smaller practices do not or, more importantly, cannot employ support staff, let alone IT staff. Conversely, providers at large healthcare agencies don’t have to spend as much time on the intricacies of the conversion. Rather, they can focus more on patient care while their IT staff works with the more time-consuming details of the EHR conversion.

Although many in the behavioral health industry support the idea of EHRs, not everyone will come out a winner in regards to the American Recovery and Reinvestment Act of 2009 (ARRA). This requires all healthcare providers and agencies to utilize EHRs by 2011. For the behavioral health arena, health information technology (HIT) funding will be allocated to the human services sector. Much of the public mental health services, as well as addiction services, are not eligible for federal funding as defined by the ARRA eligibility requirements.

Over 500 agencies and organizations in the mental health and human services field completed a 2009 survey that gauged the readiness of EHR implementation in behavioral health. Not surprisingly, cost was cited as the main reason many were not progressing with EHRs at the same rate as that of general healthcare. In response to the survey results, Mark Covall, president and CEO of the National Association of Psychiatric Health Systems said, "Health information technologies can help serve more patients more effectively and better meet the growing need for psychiatric services. The significant investment that has already been made by providers is evidence of the field's commitment to technology. But we can't keep up unless dollars are available on par with the rest of healthcare.”

The survey results showed that primary care spends twice as much than behavioral health services on HIT and three times more on IT employees. Moreover, less than half of all behavioral health services providers are currently utilizing EHRs. The picture becomes grimmer when considering budget cuts most of these providers expect in the coming years, and an increase in patients is anticipated with a decrease in reimbursements. Yet according to the study, if funding became available, behavioral healthcare providers and agencies would be able to spend more on developing their HIT capabilities such as EHRs.

As far as e-prescribing, or electronic prescriptions, general healthcare providers rarely utilize this cutting edge IT feature. Even fewer psychiatrists are believed to provide prescriptions by way of electronics. The Drug Enforcement Administration does not endorse e-prescribing of controlled substances, and this is another barrier to the usage of e-prescribing as noted by behavioral healthcare providers. These, of course, include Schedule II-IV drugs for which Chuck Klein, PhD and Netsmart’s Director of Clinical Services relates, “In behavioral health, this is a big issue. A lot of stimulants used with children are Schedule II.”

Another concern of EHR in behavioral health has to do with defining children’s healthcare standards within IT. Health Level Seven (HL7), an IT standards development organization, recently passed such standards. Safe and effective care of children is paramount the utmost importance, according to Andrew Spooner, MD, Cincinnati Children’s Medical Center and co-chairman of the HL7 Group. HL7 is also a main resource for the Certification Commission for Healthcare Information Technology.

"As vendors develop EHR systems for the care of children,” said Dr. Spooner, “they will want to conform to the Child Health Functional Profile, found under http://xreg2.nist.gov, in order to better equip clinicians in any setting to care for children."

HL7’s standard of care for children was approved by the American National Standards Institute, and HL7 will continue to identify child health certification criteria within EHR systems.

One of the many considerations in the successful transition from paper to ER for the behavioral health setting is maintaining confidentiality under all circumstances. The nature of behavioral health is especially sensitive, and most patients naturally want all of their information to remain completely confidential. Trust is essential in developing the behavioral specialist’s relationship with the patient, and the patient’s progress is largely dependent on that bond. A Harris Interactive poll in March found that 17 percent of patients withheld information from their health care professionals because of worries the information might be disclosed.

“These rates are likely to be even greater if information exchange is electronically enabled,” said Zebulon Taintor, M.D., vice chair of the Department of Psychiatry at New York University. IT may have a ways to go so that all EHR formats and usage are conducive to the essential level of trust needed between the patient and the caregiver.

Still another concern about EHRs in behavioral health was voiced recently by Linda Rosenberg, M.S.W., President and CEO for The National Council for Community Behavioral Healthcare. She said, “Note that the current federal definitions of behavioral health providers are not as inclusive as we would like and we are committed to improving and expanding existing definitions.”

Despite these barriers to EHR integration, some strides are being made. According to a recent report from the Substance Abuse and Mental Health Services Administration (SAMHSA), 46 states are currently incorporating or preparing to incorporate EHRs in state psychiatric hospitals, and are planning to integrate their use in the community mental health sector.

Other good news for behavioral healthcare and EHR was noted by Don Hevey, CEO of the Mental Health Corporations of America. He said, "Information technology is a dynamic and evolving force in behavioral health and human services. If we can break down funding barriers, more providers will be able to realize the benefits of full system acquisition and implementation, and the impact of information technology on the efficiency and effectiveness of service delivery will increase significantly."

Arguably, the government incentives, which will provide funding to Medicare and Medicaid providers under the ARRA in order to increase IT capabilities, have shed a more positive light on the EHR emergence within the behavioral health arena. For some, however, funding isn’t the driving force behind EHR implementation.

Some, if not most, behavioral healthcare providers acknowledge the advantages of a fully-integrated EHR system. Fewer medical errors are anticipated and immediate medical information during emergencies and return appointments will not only be cost effective, but it will help ensure a delivery of care where there is much less of a delay when treating patients. During emergencies or non-emergent situations, time is of the essence, and the potential for much more effective and efficient patient care is one of the greatest advantages of EHRs by behavioral healthcare providers.

In order for EHRs to meet the goal for substance abuse and mental health treatment, behavioral health information must coincide with the entire IT system. Today, EHRs are based on a primary care or medical model, and experts in the behavioral health field say there must be a unique set of standards for a national EHR system that accommodates the behavioral branch of health care.

Dr. Kevin Hennessy, SAMHSA’s Science to Service Coordinator, concurs. “Developing a consensus around standards in health information technology for behavioral health will influence the design of the overall national system. And that requires various segments of the field speaking with one voice to the larger community of experts working on system design."

SAMSHA has implemented the Behavioral Health Treatment Standards Work Group, which provides a forum to discuss how mental health and substance abuse fits into the national health information system.

Sarah A. Wattenberg, a senior public health analyst for SAMSHA, recognized this urgency. She said, “The question is how do you structure this huge national health information system and electronic health records so that they can accommodate the need for consent when that's required? And, at the same time, we need to provide the safeguards vital for behavioral health." A good question indeed.

Republished by permission of the EHR Institute, a subsidary of Core Solutions. For more information on electronic health records, sign up for a free site membership at www.ehrinstitute.org.

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