Overview of Issues: Barriers to Developing EHR in This Field

Constance Weisner, DrPH, MSWJennifer 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, MD

July 13-14, 2009

OverviewHistoryBarriers

Infrastructure Workforce Multiple system interaction Most programs are free-standing-not part of a

health plan/using the same EMR Privacy

Potential

National Policy Approach to Behavioral Health Care

Crossing the Quality Chasm’saims, rules, and strategies for

redesign should be appliedthroughout Mental

Health/Substance Use health care on a day-to-day operational

basistailored to reflect the

characteristics that distinguishMental Health /Substance Use

health care from generalhealth 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.

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

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

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.

Characteristics of the Addiction Treatment System

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 <12%

Sources – NSSATS, 2002; D’Aunno, 2004

11,600

Source 1990 2008Criminal Justice 38% 61%Employers/EAP 10% 6%

Welfare/CPS 8% 14%

Hosp/Phys 4% 3%

Referral Sources

Adolescent Treatment Referral Sources Parents - 83% Health care provider - 18% Legal system - 33% (20% Court

Mandated) Friends - 19% Mental health providers - 35% Schools - 13%

Phone Interviews With National Sample of 175 Programs regarding personnel, management, information

McL, Carise & Kleber JSAT, 2003

• 12% had closed • 13% had changed service operation

• 31% of the rest had been taken over, usually by MH agencies

Program Changes In 16 Months:

• Counselor turnover 50% per year

• 50% of directors have been there Less Than 1 year

STAFF TURNOVER!

Other Staff • 54% Had no physician

34% Had P/T physician39% Had a Nurse

• < 25% Had a SW or a Psychologist

• Major professional group - Counselors

• Modest Computer Availability– Mostly For Administrative Work– 80% Had a Computer – 50% had Web Access

• Still very little computer/software availability for CLINICAL STAFF

Information Systems:

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?

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)

Privacy (cont’d)

Continuing CareStigmaVariation in clinical and patient concerns

Opportunities

Coordination with other systemsCommunication with patients Epidemiologic surveillanceOutcomes monitoring

Using Standardized Instruments at Intake and Follow-up

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.

Thank you!