Overview of Issues: Barriers to Developing EHR in This Field

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Overview of Issues Barriers to Developing EHR
in This Field

• Constance Weisner, DrPH, MSW
• Jennifer Mertens, PhD
• Stacy Sterling, MSW, MPH
• Narrowing the Research-Practice Divide in
  Evidence-Based Medicine with Adoption of
  Electronic Health Record Systems Present and
  Future Directions
• National Institute of Drug AbuseRockville,
  MDJuly 13-14, 2009

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Overview

• History
• Barriers
• Infrastructure
• Workforce
• Multiple system interaction
• Most programs are free-standing-not part of a
  health plan/using the same EMR
• Privacy
• Potential

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National Policy Approach to Behavioral Health Care

• Crossing the Quality Chasms
• aims, rules, and strategies for
• redesign should be applied
• throughout Mental Health/Substance Use health
  care on a day-to-day operational basis
• tailored to reflect the
• characteristics that distinguish
• Mental Health /Substance Use health care from
  general
• health care.

Institute of Medicine. Improving the Quality of
Health Care for Mental and Substance-Use
Conditions Quality Chasm Series. Washington, DC
National Academies Press 2006.
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Six Critical Pathways for Achieving Aims

• Effective use of information technology (IT)
• News ways of delivering care
• Managing the clinical knowledge, skills, and
  deployment of the workforce
• Effective teams and coordination of care across
  patient conditions, services and settings
• Improvements in how quality is measured
• Payment methods conducive to good quality

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M/SU Health Care Compared to General Health Care

• Increased stigma, discrimination, coercion
• Patient decision-making ability not as
  anticipated / supported
• Diagnosis more subjective
• A less developed quality measurement
  improvement infrastructure

• More separate care delivery arrangements
• Less involvement in the NHII and use of IT
• More diverse workforce and more solo practice
• Differently structured marketplace

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Health Plans / Purchasers Recommendations (cont)

• Require all contracting organizations to
  appropriately share patient information
• Provide incentives for the use of electronic
  health records and other IT
• Use tools to reduce adverse risk selection of
  M/SU treatment consumers and
• Use measures of quality and coordination of care
  in purchasing / and oversight.
• Associations of purchasers work to reduce
  variation in reporting / billing requirements.
  

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Characteristics of the Addiction Treatment System
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Addiction Specialty Care

• 13,200 specialty programs in US
• 31 treat less than 200 patients per year
• 65 private, not for profit
• 77 primarily government funded Private
  insurance lt12
• Sources NSSATS, 2002 DAunno, 2004

11,600
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Referral Sources

• Source 1990 2008
• Criminal Justice 38 61
• Employers/EAP 10 6
• Welfare/CPS 8 14
• Hosp/Phys 4 3

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Adolescent Treatment Referral Sources

• Parents - 83
• Health care provider - 18
• Legal system - 33 (20 Court Mandated)
• Friends - 19
• Mental health providers - 35
• Schools - 13

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Program Infrastructure

• Phone Interviews With National Sample of 175
  Programs regarding personnel, management,
  information
• McL, Carise Kleber JSAT, 2003

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Program Changes In 16 Months

• 12 had closed
• 13 had changed service operation
• 31 of the rest had been taken over, usually by
  MH agencies

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STAFF TURNOVER!

• Counselor turnover 50 per year
• 50 of directors have been there Less Than 1
  year

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Other Staff

• 54 Had no physician 34 Had P/T
  physician 39 Had a Nurse
• lt 25 Had a SW or a Psychologist
• Major professional group - Counselors

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Information Systems

• Modest Computer Availability
• Mostly For Administrative Work
• 80 Had a Computer
• 50 had Web Access
• Still very little computer/software availability
  for CLINICAL STAFF

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Multiple System Interaction

• Unique to behavioral health care Most programs
  are free-standing
• collaborative care with
• Health systems
• Criminal Justice
• Welfare
• Important issues for internal EMRs and
  cross-system communication
• Should privacy regulations be the same for each
  system?
• Where the program is embedded?

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Privacy

• Prevent disclosure of addiction treatment and
  diagnoses also create barriers to accessing data
  and complicate coordination of care, especially
  with regard to EHRs and electronic
  networks.(Institute of Medicine, 2006)

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Privacy (contd)

• Continuing Care
• Stigma
• Variation in clinical and patient concerns

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Opportunities

• Coordination with other systems
• Communication with patients
• Epidemiologic surveillance
• Outcomes monitoring

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Using Standardized Instruments at Intake and
Follow-up
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Conclusion

• Barriers are large and involve characteristics of
  the treatment system, regulatory issues,
  workforce issues, and long-term work styles.
• Opportunities are increasing and field is ready
  to grapple with these issues.

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Thank you!