Mental Health Data Missing from Electronic Health Records

The article in HealthLine underscores the issues of developing a total electronic health record. 

Despite federal desires (CMS & HHS )to totally wrap medical records into an electronic format there remain several critical issues important to guarding privacy of patient mental health information. The Federal Definition of an EHR is extends beyond the aspects of recording patient data. They define an EHR with a broad pen including capabilities of meaningful use capturing data for analytic purposes.

By convention, and a long ethical history, providers have always guarded the privacy and protection of patient’s medical records, especially for emotional disorders. The physician has always been the health information collection agent in a fiduciary manner.  If the emotional and behavioral aspects were put into the EHR it would greatly endanger patient’s reputations, employment, and even  discrimination by health plans.  The Affordable Care Act  has markedly reduced the risk of non insurability by law. The other issues have not been addressed.

There is a spectrum of behavioral disorders ranging from severe organic brain disease resulting in schizophrenia and bipolar disorders to mild neurosis and anxiety disorders.  It is a gray playing field and somewhere in the middle it crosses over from ‘medical disorder’ to ‘behavioral disorder" in the reimbursement system. (What's in an ICD code?)

Health Plans discriminate between the two on a reimbursement basis as well. Co-pay for visits to a psychologist are higher than medical visits. In some cases even when an MD psychiatrist is involved the visiit is not treated as a medical visit even if medications are managed by the psychiatrists.

Often the staff at a ‘behavioral clinic’ do not discern the difference and bill improperly.

The federal government is interested in interoperability for purposes of data analytics. The experts who advise congress and HHS are misguided and naive, positing that developing this system will improve the quality of health care.  

Mental health issues should have a higher level of privacy protection. Not every provider should have access to the mental health record of every patient. That is a shot gun approach prone to much collateral damage. Mental health records should only be in the EHR in a higher level of protection with additional access granted only by the patient. The level of emotional dysfunction will be a major determinant in the importance of the information.

In a time when medical care has become patient centered the patient will have the final word on release of potentially harmful behavioral information. It is now established that the patient owns his own data even while it resides in the EHR program. He owns it and no one can take it without the patient's permission. (case precedence ?)

There was a time when public figures could enter a hospital and/or a provider's office and be certain the visit would not be made public. . Politicians, celebrities and other high level people expected this as the normal course of the day.  So too should it extend to all patients with equanimity. Placing this information in the EHR in an unrestricted fashion is not a good thing to consider.

Neither can a metric be applied in this gray zone. Most of it is ‘judgment’  The word that EBMers do not have in their vocabulary.

Unexpected release of protected information either medical or emotional can result in a serious alteration of a patient’s life, and/or employment. Employers like to have this information to determine suitability for employment. Allowing employers or any non medical person not directly involved in the patients health care would be akin to opening Pandora's box.

The Feds are wrong about this, as they have been in most health quality and reimbursement issues. There is no real necessity for inclusion in the EHR the Feds would like it but they are not going to get it unless providers cave in and are once again blackmailed and extorted by another carrot and stick scheme so common to our corrupt system of governing.

Healthcare Policy Getting Reimbursed: Its Complicated

Billing and Delivery for health services has become extremely complex. Although fee for service (volume-based care) is deemed to be on it's deathbed by proponents of payment for quality of care and outcomes, the complexity of obtaining a payment becomes more of a juggernaut. This is occuring in the face of  a system that is not ready to convert to accountable care organizations. The infrastructure for such a conversion is completely absent. The marketplace has abundant vendor offerings.  
Although the majority of health providers now are using electronic health records and are required to be certified for meaningful use, many providers are ignoring these standards.  Interoperability remains a major hindrance to  connecting all the systems of an accountable care organization

In order to address this issue and many others take this course.

You will learn about:

• The relationship between healthcare expenditures and provider compensation.
• Payment models under Medicare and the Affordable Care Act.
• The future distribution and cost of healthcare services

• Define the 3 types of provider payment schemes.
• Recite the types of national healthcare expenditures and the proportion that each contributes to the total spending.
• Compare the compensation for US and international physicians as a multiple of gross domestic product per capita.
• Describe the methods by which Medicare determines physician payments.
• List the provider components of a healthcare delivery system.

• Describe how healthcare services will be distributed in the future.
• List the types of costs associated with healthcare delivery.
• Describe bundled payments under the Affordable Care Act and how bundled payments are different from prior programs such as global surgical fees.
• Define the incentives to achieve Medicare bonus pay within a Pay-for-Value program.
• Review the concepts in the case studies.

Health Care Policy: Delivery and Payment

Mayo Clinic conversion from Cerner EHR to EPIC EHR

The Mayo Clinic in Rochester, MN has clinics in Florida, Arizona, and also MayoClinic Health System  are about to convert their electronic health record system.

The large health care system faces the challenges of RCM (Revenue Cycle Management) which the Affordable Care Act proposes to mandate. This change converts the fee for service model to one of reimbursement for quality of outcomes (Value based payment model) and Pay for Performance and is not based upon volume. This  is an enormous change about to take place.

The HIT department at Mayo Clinic is quite large, supporting clinical, administrative and educational functions. Mayo Clinic is heavily invested in  Cerner's EHR, and 'patching'  software requiring multiple changes for RCM, measuring outcomes, attesting to meaningful use present a formidable exercise at considrable expense. Ostensibly the number crunchers, clnicians, and administrators believe a fresh start allows for a more efficient transition both financially and in training staff to meet the new regulatory standards.

Cris Ross, CIO for Mayo Clinic explains,

'The scope of Mayo's practice is very large, so we have a lot – a lot – of detailed decisions to make'

John Noseworthy MD, President and CEO of Mayo Clinic, states,  “We’re confident in choosing Epic as our strategic partner as we continue to enhance Mayo Clinic’s excellence in health care and medical innovation,” said John Noseworthy, MD, Mayo Clinic's president and CEO, in a statement announcing the partnership.





The Mayo Clinic  Health System is a large health care enterprise. They have many facilities dispersed throughout the United States, and interoperability is a key factor for them. Their old system from Cerner did not provide this functionality, nor did it meet the requisites for Meaningful use and/or conversion from fee for service reimbursement to a value based reimbursement system. Redesigning or patching a legacy system would be too expensive and may not have provided the changes, or future changes to comply with CMS requirements.  User friendliness may have also contributed to changing to an entirely new software vendor.

The original concept for EHR was to make  a record more legible and to store data that was easily retrievable. This has been expanded to include data fields which allow analytics

The technical aspects to achieve interoperability, a built in tree to compute outcome analytics and quality of care go beyond this blog. In fact health clinicians must now depend upon others to design systems which will integrate record keeping with all the other mandates of the Affordable Care Act, and Accountable Care Organizations.

Accountable Care Organizaitons may well go beyond one health care provider, both clinics and hospitals. In some cases depending upon whether it will be an IPA, hospital, or insurer, each responsible organization will need to use appropriate software to integrate the ACO.


Early experience has not been all that successful.  A few 'Pioneer' ACOs are operational, but several Pioneer organizations have failed, including the Sharp Health System in San Diego.

Some insurers are forming their own ACOs as an alternative for fee for service reimbursement. It promises to be a learning experience for all users

The Mayo Clinic has always fashioned itself as a 'leader". It's partnership with Epic signals a change. Kaiser Permanente already uses Epic for their system, replacing it's original system from IBM. Called Kaiser Connect it bases it's overall operation on Epic with some additional software modules to build upon it's success.

Kaiser's CEO states it's operational infrastructure upon EPIC .

Philip Fasano: We have every piece of information about that patient available to us to draw upon. The primary care physician has all the information about the patient, the specialists have all the information about the patient, and anyone they encounter in any of our hospitals has it as well. He or she can see the patient's health history, diagnosis by other providers, lab results, and prescriptions are all there. X-rays are stored digitally and are there. That information is also available if a patient goes to the ER.

Cost is significant, About $4 billion, a substantial amount of money, but we have 9 million members [so it costs about $444 per member]. This is not a one time investment.  You have to invest continuously in the infrastructure over its lifetime. People have to recognize that these systems are life-critical once implemented, so you have to invest in the infrastructure to be sure they are always on.  InfoWorld: What would it cost nationally to do what Kaiser did?Fasano: The health care reform act states that "meaningful use of technology" by providers nationally would be $11 billion. At the time, I said, "That's a nice down payment." It will cost tens of billions of dollars to implement this.

Kaiser, says Fasano blazed a new path, with considerable challenges and failures, a price from which  all future users will benefit.

The new system was built with Epic Systems, a specialist in electronic health records that is now one of the top two EHR vendors, along with Cerner.)

Progress on the Frontiers of Health and Medicine

The frontiers of medicine are not only in the development and transformation of delivering health care, but is also a physical impediment to delivering a level of quality health care.Rural health care presents unique challenges for delivery of care. There are fewer providers, facilities, and less economic support.

As described by Leila Samy, Meghan Gabriel, and   Jennifer King on HealthITBuzz , 

Leila Samy

  

                                                                Meghan Gabriel
                                                                                                               Jennifer King

              

Critical Access Hospitals (CAHs), some with a census of fewer than 10 patients, are the smallest of the small rural hospitals. In some regions, such as frontier areas, a CAH may be the only local health care provider serving an area the width of the state of Rhode Island! CAHs are small, geographically isolated and have limited resources.

CAHs are found in every region of the country, and represent roughly 30 percent of hospitals nationwide. Often serving as the focal point for all health care services in a rural area, CAHs often own and run the local rural health clinics and skilled nursing facilities. They may also be responsible for public health and emergency medical system services. These hospitals extend services to places where they wouldn’t otherwise be available. And those are the reasons why it is important for CAHs to have access to health IT systems and capabilities.

As of 2013, 89 percent of CAHs had an EHR in place; 62 percent of CAHs with an EHR had a fully electronic health record system, and 27 percent had a health record system that was part electronic and part paper.

Most CAHs adopted (as of 2013) or planned to adopt (by the end of 2014) the health IT capabilities evaluated in this study (i.e., telehealth, teleradiology, care coordination and health information exchange with other providers and patients).

As of 2013, CAHs reported the highest rates of adoption for teleradiology (70 percent) and telehealth (59 percent) capabilities. Fewer CAHs reported other capabilities related to electronic exchange of key clinical information with other providers. Even fewer (15 percent) of CAHs reported patient engagement capabilities (i.e., offer patients ability to view, download and transmit their health information

Among the challenges to health IT adoption among CAHs, financing and workforce related challenges were most commonly reported.

CAHs that pooled resources with other hospitals were more likely to have EHR and capabilities related to health information exchange and care coordination, compared to those that did not pool resources or engage in group purchasing.

CAHs with faster Internet upload speeds were more likely to have the capability to provide patients with the option to view, download, and transmit their health information compared to those with slower upload speeds.

The Federal Government is offering funding opportunities and offers Creative Solutions to Expand  Rural Health IT Funding

Benefits of Health IT adoption among CAHs and other small, rural hospitals

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The Evolution of Health Information Exchange, 2014

It can be said that the first part of the 21st Century in medicine has been the wave of information technology.  The capitalization of this relatively new department has diverted much funding from other needs in the health care industry.

The addition of HIT required federal underwriting. The ‘incentive’ was more of a negative reward/penalty instrument to force adoption of IT.  In order to maximize reimbursement from CMS hospitals are incentivized to reduce readmissions, and report meaningful use. Meaningful use follows a progressive course, escalating over time until fully implemented. Hospitals have many more stages than clinics or individual providers. Providers and hospitals alike must ‘attest’ to this functionality and demonstrate they are reporting. Failing to do so by a specific date is penalized by a reduction in reimbursement for services.

Much importance has been assigned to this effort, including improved outcomes, decreased expenses, improved patient experiences, transparency of information, accessibiliity of information for patients and providers and the unproven promises of ‘BIG DATA’

It will take some time to determine if these processes will  reduce expense or flatten the rate of inflation of health cost.  Built into and hidden from view is the cost of obtaining the data, and analytics.  A substantial IT investment and personell are added to the equation.  

The peverse nature of government is to spend more to save more…Government is fueled to expand and self-replicate ad infinitum.

Other industries such as the automotive business have profitted from BIG DATA, and it is hoped that by translating it to health care there will be dividends in treatments, cost reduction, safety, and better outcomes.

The Evolution of Health Information Exchanges

My  experience in this area began in 2005 as I led a group of physicians to consider a regional health information exchange.  It was a slow but fertile beginning.

We all focus on what is now and what lies ahead, that challenge can be justified by a brief but important look at our past accomplishments which are considerable.

Much has been accomplished, by many, and at relatively little expense in the planning phases of  HIE.  Early planning and project management time expenses were donated at no charge by physician leaders, medical societies, and interested vendors.

Well intentioned leaders do not have to spend billions of dollars to study or plan a project of this scope.  

These thoughts were corroborated as reviewed written and verbal correspondence for the early meetings of the Inland Empire Health Information Exchange (Riverside, Callifornia)

Neither can one forget the prescience of  President George W. Bush by forming the Office of the National Coordinator of Health Information Technology, Don Berwick M.D. and their successors.

Physicians were dragged into the mix as naysayers, not wanting more complex procedures to interfere with patient management responsibilities. We are now well along the way and there will be no turning back.

Even more than the abilit fo providers to exchange medical information is the added dividend for analytics, and support for accountable care organizations.