Behavioral Health EMR Implementations
Many large hospital systems offer behavioral health services as part of their continuum of care, so, it is important to fill in the gaps that behavioral health has when it comes implementation of an EMR. Some examples of why it is important to offer behavioral care services that are supported by a robust EMR include:
- One in eight or nearly 12 million ER visits in the U.S. are due to mental health and/or substance use problems in adults. This is the most costly venue for care delivery. Mental Disorders and/or Substance Abuse Related to One of Every Eight Emergency Department Cases. AHRQ News and Numbers, July 8, 2010. Agency for Healthcare Research and Quality, Rockville, MD. h p://www.ahrq.gov/news/nn/nn070810.htm
- Major depression is considered equivalent (in terms of its burden on society) to blindness or paraplegia. Schizophrenia is equivalent to quadriplegia. Disability Adjusted Life Year, DALY, Daly 2004
The gaps that are often identified in a behavioral health EMR include:
1. Providers: Most behavioral health providers are not MDs. In fact, primary care physicians spend limited time with patients and are often hesitant to diagnose and treat behavioral concerns. Most behavioral health providers are clinicians with masters or doctorate degrees who have been licensed by their state(s) to diagnose and treat behavioral health disorders.
2. The diagnostic process and tools: Behavioral health disorders are the only serious, chronic illnesses that are diagnosed based solely on self-report. The tools used to assess the behavioral health patient's mental status and substance abuse patterns are very different than the traditional medical diagnostic tools of imaging and lab work. Behavioral health diagnostic tools are most often elaborate question and answer tools that can be both clinician-administered and self-administered. Behavioral health clinicians use tools such as the Beck Depression Inventory (BDI), Generalized Anxiety Disorder scale (GAD 7), and the Diagnostic and Statistical Manual (DSM IV). These tools need to be incorporated into the data capture and workflow built into an EMR. Additionally, behavioral health providers are required to develop elaborate treatment plans with the patient's participation. Non-behaviorally focused EMRs typically don't have tools built in for this and must be built (or ignored). If ignored, the EMR becomes nothing more than a word processor.
3. Customization will always be required: While there are multiple behavioral health specific EMR vendors in the marketplace and enterprise-wide EMRs that can be configured to cover behavioral health, customization will be required to meet multiple state specific mandates, practitoner specialty requirements and federal privacy rules that apply to behavioral health. Although there are challenges when implementing an EMR in behavioral health, the successes are growing. For example, the state of New Jersey has been successful in bridging the gap between behavioral health and EMRs.
The following recommendations help to ensure a positive implementation outcome:
- Create a small but specific implementation team that aligns with behavioral health leadership during the build and test period, so all build and testing work is completed in a collaborative manner.
- Build using the most commonly used diagnoses and their DSM IV criteria into the EMR to make it easy for providers and therapists to use drop-down lists to create the diagnostic picture of the patient.
- Build using ASAM criteria, so chemical dependency staff s can more easily complete treatment planning.
- Design within the ‘tighter than HIPAA' federal constraints that govern confidentiality of patient information for patients receiving chemical dependency treatment (i.e., CFR 42).
- Involve trainers and testers in the workflow discussions.
To avoid putting a round peg in a square hole, it's essential to understand the variances in the behavioral health setting and address them in workflow, data capture, information exchange, provider engagement, and administrative requirements and incorporate them into the EMR project plan, design, and implementation.