HHS proposes adding behavioral health to EHR program

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If the Department of Health and Human Services has its way, it will be adding behavioral health providers to the Electronic Health Record Incentive Programs.

That category of providers includes psychiatric hospitals; community mental health centers; residential and outpatient mental health and substance abuse disorder treatments facilities; as well as psychologists.

Currently, federal rules prohibit behavioral health providers treating mental and substance abuse disorders from receiving incentive payments for implementing EHRs that meet Meaningful Use criteria. However, in its Fiscal Year 2017 budget submission to Congress last week, HHS included a legislative proposal to add certain behavioral health providers to the EHR Incentive Programs.

“The expansion is meant to facilitate the integration of behavioral health and medical care, and promote the sharing of clinical data needed to provide better patient-centered care,” HHS says in its proposal.

The proposed inclusion of behavioral health providers comes on the heels of a bill introduced last year by Reps. Tim Murphy (R-Penn.) and Eddie Bernice Johnson (D-Texas). That bill, called the Helping Families in Mental Health Crisis Act, would allow behavioral health and addiction treatment providers to receive payments though the EHR Incentive Programs.

“We strongly support advancing the use of information technologies, including electronic health record systems, to support integrated behavioral healthcare,” says Dina Passman, acting team lead for health IT at the Substance Abuse and Mental Health Services Administration (SAMHSA), the agency within HHS that leads public health efforts to advance behavioral health. “Expanding incentive programs or any funding opportunities for the field to include more behavioral health providers than have previously been covered supports our goals.”

Cara English, director of the Doctor of Behavioral Health program at the Cummings Graduate Institute for Behavioral Health Studies, is also a supporter of efforts to extend Meaningful Use incentives eligibility to include mental health treatment facilities, psychiatric hospitals and substance abuse treatment facilities, as well as clinical psychologists and licensed social workers.

English is seeing “a transition of the healthcare industry from siloed, single provider organizations to a true model of collaborative care across a community of independent providers. This is a sea change within healthcare in which we work together using our electronic health records—that’s never been done before—to access the behavioral and emotional component of care and providers that have been missing all along. In the end, it’s all about patients and improving the quality of their care.”

Passman argues that data regularly released by the Office of the National Coordinator for Health IT demonstrates that the EHR Incentive Programs have “improved uptake” of eligible professionals and hospitals in adopting HIT. “We could therefore assume that would also be the case if behavioral health providers were also included,” she says. “There’s definitely a huge amount of interest in the use of HIT among our stakeholders and also a lot of questions around not just how to fund that technology but what the steps are in acquiring it and implementing it in a treatment setting, and all that that entails.”

Not surprisingly, according to Erin Dormaier, transformation services manager for the Colorado Regional Health Information Organization (CORHIO), EHR adoption rates for behavioral health providers have been much lower compared with other provider groups that have been eligible for the Meaningful Use program. “It’s definitely needed to pull them into the program,” says Dormaier. “They’ve really missed out on the incentive payments that could help them adopt this technology.”

Nonetheless, Toria Thompson, CORHIO’s behavioral health information exchange coordinator, makes the case that some community health centers in Colorado that employ large numbers of psychiatrists have already benefitted from Meaningful Use payments to finance EHR projects. Thompson also notes that most, if not all, of the state’s 17 community mental health centers have EHRs. “However, there are other providers in Colorado, such as substance use disorder treatment centers that are typically smaller organizations and have not made investments in EHRs, who would benefit tremendously.”

English, however, is not concerned that behavioral health providers are behind in implementing and using EHRs, compared with others that have been participating in the Meaningful Use program for years now, nor does she think they will have a difficult time catching up.

“As a behavioral health provider myself, I’ve been using an EHR and we have Meaningful Use built into the system that we use at my medical clinic,” English asserts. “At the same time, behavioral health providers would benefit from the same kind of technical support that other providers have received in being able to hit the ground running.”

“The behavioral health community has already been disadvantaged by being less able to get support to implement these systems, so any help is appreciated and moves the field forward,” adds SAMHSA’s Passman. “All providers who are onboarding this technology could use additional help. There’s definitely a need for technical assistance to help move the behavioral health field forward with this technology.”

“The purpose of encouraging behavioral health providers to get electronic health records is so that we can all be on the same team,”

While Andrew Boyd, MD, a health informatics professor at the University of Illinois at Chicago, is in favor of adding behavioral health providers to the EHR Incentive Programs, he contends that there are major obstacles to the sharing of behavioral health information that Congress may not be able to solve, namely the fact that these records are currently inaccessible based on policy restrictions and state laws. In addition, Boyd points out that the definition of “behavioral health providers” varies state by state, based on regulations governing who is licensed to practice.

“The purpose of encouraging behavioral health providers to get electronic health records is so that we can all be on the same team,” says Boyd, whose research focuses on EHRs and the areas of data simplification and integration. “Storing behavioral health data in an EHR is a good first step, but we have a culture and policy environment that prohibits this from becoming a reality. Even if we can change policy, changing provider attitudes is going to be even harder.”

To alleviate some of the barriers to information sharing, SAMHSA earlier this month released a proposed rule modifying 42 CFR Part 2, a portion of federal law that limits the disclosure of identifiable information by a federally assisted substance abuse treatment program to any entity, even for treatment, without signed consent from the patient to authorize the disclosure, with limited exceptions. It also restricts the re-disclosure of that data by the receiving entity for any purpose without consent.

“The last substantive update to these regulations was in 1987,” states SAMHSA’s proposal, which is currently open to public comment. “Over the last 25 years, significant changes have occurred within the U.S. healthcare system that were not envisioned by the current regulations, including new models of integrated care that are built on a foundation of information sharing to support coordination of patient care, the development of an electronic infrastructure for managing and exchanging patient information, and a new focus on performance measurement within the healthcare system. SAMHSA wants to ensure that patients with substance use disorders have the ability to participate in, and benefit from new integrated healthcare models without fear of putting themselves at risk of adverse consequences.”

These confidentiality rules were developed to give patients confidence in getting substance abuse treatment without fearing disclosure of the treatment. SAMHSA’s Passman acknowledges that there are challenges associated with EHRs and substance abuse and alcohol treatment data.

However, Deborah Peel, MD, founder of the organization Patient Privacy Rights and a practicing psychiatrist/psychoanalyst, believes this SAMHSA proposal will destroy the privacy needed for treatment for substance abuse and psychiatric diseases.

“It will drive millions more people away from seeking treatment for diseases that can literally drive them to death by overdose or suicide,” says Peel. “Today 50 percent of the public lies and omits health information when seeking treatment because electronic health systems disclose and sell their data without their consent. The public knows their electronic records are controlled by the health technology industry and aren’t private. So they act to protect themselves by hiding information or delaying or avoiding treatment. Today’s EHRs cause bad health outcomes.”

Boyd agrees that historically there has been a “special trust” between the behavioral health providers and patients. As a result, these providers almost never surrender behavioral health notes—such as psychiatric and psychotherapy notes—even for court cases, he says.

“From a medical point of view, sharing some or all of the records makes sense, and behavioral health providers using electronic health records is a good first step,” Boyd concludes. “But, we should have a discussion on a national basis about what is and is not appropriate, recognizing this special relationship between behavioral health providers and patients. It’s a delicate balancing act.”

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