Behavioral health constitutes an important area of focus for the application of health information technology (HIT), since as many as 20% of people are afflicted with a behavioral health issue at one time or another during their lifetime, and HIT has the potential to enhance their care.1 Behavioral disorders commonly include anxiety, depression, and bipolar disorder, and may also include disturbances of thought such as schizophrenia and psychosis, as well as borderline personality disorder, panic attacks, and post-traumatic stress disorder.2 Treatment may be multifactorial, including behavioral therapies, psychotherapy, and pharmacologic therapy.2 In many instances, treatment is rendered by clinicians in the primary care setting, whereas the more complex cases are often treated by behavioral health specialists in specialized clinics, such as behavioral health organizations.3
The burden of behavioral health issues may also complicate the management of chronic medical conditions including diabetes, cardiovascular disease, and cancer. For example, patients with behavioral health issues may be less inclined to adhere to chronic medical regimens for diabetes, hypertension, or lipid management, leading to excess levels of diabetic or cardiac complications, more frequent hospitalizations, and more frequent readmissions. Pharmacologic management is further complicated by variable compliance with regimens, both for the primary behavioral health issue and also for comorbid medical conditions, such as diabetes. In addition, some chronic medical conditions, including diabetes and cardiovascular disease, are associated with depression, rendering the management of these conditions highly interdependent.4 To make things even more complex, some behavioral health medications, such as atypical antipsychotics, may be a risk factor for or exacerbate an existing underlying metabolic medical condition. Hence, the management of patients with multiple comorbidities including a mental health issue and a chronic medical condition can be extremely challenging to the clinician.
In addition, some patients with behavioral health problems are un- or under-insured and do not have adequate coverage for their behavioral illness.5 Such patients are at risk for fragmented and uncoordinated care. The problem is exacerbated in complex patients who have two or more chronic conditions; these patients are at great risk for uncoordinated care of both conditions. Finally, patients with mental health conditions are at high risk of developing substance abuse issues.6
Key Areas for HIT
A variety of HIT tools, including health information exchange (HIE), mobile health, electronic health records (EHR), personal health records (PHR), home monitoring systems, decision support systems, and other technologies, can be applied to meet the challenges of medication management and adherence, care coordination, and management of comorbid conditions in behavioral health.7
Medication management is the first key area where HIT innovations can help improve the quality of care delivery in the behavioral health domain. Standardized electronic screening tools can identify and characterize behavioral health issues, especially in the primary care setting. These tools can also be used to monitor patient progress in the behavioral health organizational setting. Clinicians can deploy electronic decision support tools to assist in medication management; these tools can provide evidence-based recommendations for pharmacotherapy based on results of screening tests as well as the presence of underlying medical conditions. Support tools can also assist in determining when referral for specialty care is appropriate. Algorithms can help with appropriate selection of specific agents and can help to avoid unnecessary polypharmacy. Decision support tools residing on the EHR (including on handheld mobile devices) can provide recommendations regarding dosing, allergies and adverse reactions, drug-drug interactions, and drug-laboratory interactions including hepatic and renal function.8
Furthermore, these tools can access pharmacy databases to determine whether a particular patient has been filling prescriptions on a regular basis. Hence, compliance with the regimen can be monitored. Drug selection can be made patient-specific, so that drugs that would exacerbate an underlying medical condition, such as certain atypical antipsychotics, can be avoided in given patients. Metabolic complications such as weight gain, elevated blood glucose, and hypertension can be monitored in patients through home monitoring devices and the data routed back to an analytical engine via a robust HIE. Vendor solutions, such as home monitoring programs, exist that can track these parameters and monitor incoming data for adverse events via an HIE-based rules engine, which analyzes data according to specific rules set by clinicians.
Mobile devices that can access a powerful HIE with a rules engine could implement a robust medication management program for behavioral health. With a mobile device, a primary care or behavioral health clinician can electronically prescribe, review evidence-based recommendations about appropriate pharmaceuticals and dosing schedules, watch patients for metabolic complications, and monitor pharmacy records for adherence. 9
Care coordination is a second key area for HIT implementation in the behavioral health arena. At the present time, there is a paucity of data exchange between primary care clinicians and behavioral health specialists. Part of the underlying problem is that these clinicians generally work in very different settings. The stage 2 federal Medicare and Medicaid Meaningful use program now requires clinicians to demonstrate that they can electronically transmit clinical data to clinicians in other settings. The Meaningful-Use program was created under the American Recovery and Reinvestment Act (ARRA) and provides incentives to eligible providers for the adoption and meaningful use of certified EHRs.
As the adoption of behavioral health–specific EHRs improves, there will be more opportunities for behavioral health and primary care clinicians to exchange data. One possible solution is the Nationwide Health Information Network Direct Project, sponsored by the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology.10 In this setting, the primary care clinician can send an electronic referral to a behavioral health specialist using an encrypted secure e-mail over an HIE. The electronic format will accommodate any type of attachment, including PDFs, Word documents, radiographic images, and structured data files that can be incorporated directly into the receiving clinician’s EHR. In addition, a continuity of care document (CCD) that provides basic information about the patient, including problem lists, allergies, medication lists, laboratory data, and other pertinent information, can be attached.11
Given that there is an acute need to accommodate behavioral health issues in the Direct Project, there is an opportunity to enhance the CCD. For example, information about suicide risk, housing status, substance use, and so on could be incorporated into the CCD format. Since the Direct Project sends data directly from one provider to a specified second provider, the document can be compliant with consent rules. Any protected information about substance abuse cannot be released or redisclosed without patient consent. Hence, the consent information can also be incorporated into the CCD.7
Management of comorbid conditions is a third key area of behavioral health ripe for HIT intervention, in addition to helping with care coordination and medication management for the behavioral health issues per se. For example, patients with behavioral health issues and diabetes are at great risk of having poor diabetic control. A robust program of home healthcare monitoring along with close coordination between the primary care clinician and the behavioral health specialist can help to ensure that the diabetes and associated cardiac risk factors such as hypertension are well controlled. Daily home monitoring of blood glucose data, blood pressure, and weight can detect any adverse trends. These data can be transmitted from the home monitoring devices to an HIE where an analytic engine continuously monitors for adverse trends. Any alerts are sent simultaneously to a care manager at the primary clinician's office, as well as to the behavioral health provider, so that all providers can reinforce the need to control these metabolic parameters.
In addition, the clinicians can monitor medication adherence to antidiabetic, antihyperlipidemic, and antihypertensive agents. Pertinent laboratory data such as hemoglobin (HbA1c), electrolytes, blood urea nitrogen (BUN), creatinine, glucose, fasting lipids, and liver function tests can be collected over the HIE in structured format so that the results can be directly entered into the primary care clinician's EHR as well as the behavioral health clinician’s EHR. In addition, the decision support software in the analytical engine can flag any adverse trends for clinician review.
Privacy Concerns
While HIT solutions bring great promise, care must be taken to ensure strict privacy of all records, since there are complex requirements under both the Health Insurance Portability and Accountability Act (HIPAA) and Substance Abuse Part 2 laws and regulations (42 U.S.C. § 290dd-2 and 42 CFR Part 2).12,13 The substance-abuse regulations apply especially to protected substance-abuse information and include strict requirements regarding disclosures and redisclosures. In addition, there are a variety of state-specific laws and regulations that may apply more broadly to behavioral health data in electronic systems. This topic has been reviewed in great detail in an earlier article in this series.5
Barriers to Adoption
Behavioral health providers have traditionally been underutilizers of HIT, with only minimal adoption.14 One barrier to adoption is that the federal Medicare and Medicaid Meaningful Use incentive program covers only a certain segment of providers in the behavioral health community. The Medicare program is implemented under the auspices of the Centers for Medicare and Medicaid Services (CMS) with input from other federal agencies and offices such as the Office of the National Coordinator for Health Information Technology. The Medicaid program is administered by the states with funding from CMS. Psychiatrists and psychiatric nurse practitioners are eligible for the Meaningful Use incentive program under the ARRA; however, other behavioral health providers such as psychologists, clinical social workers, community mental health centers, and psychiatric hospitals are not eligible. Legislation to remedy this situation was introduced in August 2013 by Rep. Tim Murphy (R-PA) and Rep. Ron Barber (D-AZ). The bill is called the Behavioral Health Information Technology Act of 2013 (HR 2957), and is pending review in Congress at the time of this article.15
Another barrier to adoption is that commercially available EHRs generally lack the logic to implement the complex consent rules that are required to manage patient consent and to control re-disclosure of protected substance- abuse treatment information. Such information needs to be specifically tracked by the EHR, because once introduced into the EHR system, this protected information cannot be further disclosed without specific consent.5 Many clinicians who treat patients with behavioral health conditions, especially those in primary care, are not aware of these complex regulatory requirements. Furthermore, the rules governing exchange of this protected information through an HIE are also complex and not easily implemented.5 There are also myriad state regulations regarding protected behavioral health information, making it difficult for vendors to develop a national solution.7
Conclusion
There is an enormous opportunity to adopt HIT tools, including HIE, mobile health, EHRs, personal health records, home monitoring systems, decision support systems, and other technologies, to meet the challenges of medication management and adherence, care coordination, and management of comorbid conditions in behavioral health. However, there are still significant policy barriers to adoption that will need to be overcome in order to move the opportunity to reality.7
REFERENCES
1. Substance Abuse and Mental Health Services Administration. Mental Health, United States, 2010. HHS Publication No. (SMA) 12-4681. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012.
2. National Alliance on Mental Illness.
What is mental illness: mental illness facts.
www.nami.org/template.cfm?section=about_mental_illness. Accessed Aug 25,
2013.
3. New York State Office of Mental
Health. Behavioral Health Organizations Implementation.
www.omh.ny.gov/omhweb/bho/. Accessed October 12, 2013.
4. Egede LE, Zheng D, Simpson K. Comorbid
depression is associated with increased healthcare use and expenditures
in individuals with diabetes. Diabetes Care. 2002:25:464-470.
5. Figge HL. HIT and behavioral health: the challenges of data exchange and privacy. US Pharm. 2012;37(12):HS16-HS18.
6. Martins S, Gorelick D. Conditional
substance abuse and dependence by diagnosis of mood or anxiety disorder
or schizophrenia in the US population. Drug and Alcohol Dependence, 2011;119:28-36.
7. U.S. Department of Health and Human
Services. Office of the National Coordinator for Health Information
Technology, and RTI International. Behavioral health roundtable.
Published September 2012.www.healthit.gov/sites/default/files/bh-roundtable-findings-report_0.pdf. Accessed October 12, 2013.
8. Figge HL. Computerized clinical decision support and drug interaction databases. US Pharm. 2012;37:47-49.
9. New York State Office of Mental
Health. PSYCKES: Psychiatric Clinical Knowledge Enhancement System.
Updated November 8, 2012.
www.omh.ny.gov/omhweb/psyckes/information.html. Accessed October 12,
2013.
10. U.S. Department of Health and Human
Services. Office of the National Coordinator for Health Information
Technology. Direct Project.
www.healthit.gov/policy-researchers-implementers/direct-project.
Accessed October 12, 2013.
11. Health Level Seven International. HL7/ASTM Implementation Guide for CDA® R2—Continuity of Care Document (CCD®) Release 1. www.hl7.org/implement/standards/product_brief.cfm?product_id=6. Accessed October 12, 2013.
12. Figge H. HIPAA: privacy, security, and pharmacy information technology. US Pharm. 2011; 36(11):78-81.
13. U.S. Department of Health and Human
Services. Legal Action Center for the Substance Abuse and Mental Health
Services Administration. Frequently asked questions. Applying the
substance abuse confidentiality regulations to health information
exchange (HIE).1-17. www.samhsa.gov/HealthPrivacy/docs/EHR-FAQs.pdf.
Accessed August 25, 2013.
14. The National Council (2012). HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health: Report on the 2012 National Council Survey.
National Council for Community Behavioral Healthcare.
www.thenationalcouncil.org/wp-content/uploads/2012/10/HIT-Survey-Full-Report.
Accessed October 12, 2013.
15. HIMSS News. New bill would extend EHR
incentives to behavioral health. August 23, 2013.
www.himss.org/News/NewsDetail.aspx?ItemNumber=22026. Accessed October
12, 2013.
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