Decision support is in its infancy

The core function of electronic health records (EHRs) is to preserve data about patients and their care. To complement EHRs and maximize use of those data, healthcare organizations of all kinds are moving forward in the crucial area of developing and using clinical decision support (CDS) tools.

CDS is a loose term and covers a lot of ground. For behavioral healthcare professionals, the main areas of interest are CDS software programs that can help clinicians perform patient assessments and create treatment plans (thereby automating some functions); look up clinical information; prompt clinicians with alerts, warnings, and advice; document care; and manage medications. Thus, CDS tools have the potential to help busy clinicians improve the quality—and safety—of care.

Candace Cohen, MD, a psychiatrist at the Mendota Mental Health Institute, a state of Wisconsin facility in Madison, was involved in planning a clinical information system for the state of Wisconsin's behavioral healthcare facilities. Although the plans have not yet been implemented, Dr. Cohen's experience helped her crystallize what challenges behavioral health providers will face in developing and using CDS tools.

For example, she cites the need for clinicians to be able to electronically document progress notes but having the ability to limit the amount of “free text” in a record. Free text is unstructured narrative (descriptive writing) as opposed to, for example, electronic checkoff lists. Although free text is a large part of many paper and electronic behavioral health records, software designers would like to cut down on the amount of free text in EHRs in favor of drop-down menus with checkoff lists (such as those familiar to users of Microsoft Windows programs). This allows an electronic system to be structured to offer CDS tools, such as clinical alerts, access to clinical information (knowledge bases) for assistance with treatment planning, and analysis of EHRs on a meta level for quality improvement purposes.

Industry experts agree that only a small percentage of behavioral healthcare professionals are working with CDS tools, and many who do are in hospital-based integrated health systems, which have more experience with EHRs and other electronic applications. Factors for this include the relatively high cost of such tools and behavioral healthcare organizations’ small budgets for information technology. Even large community mental health centers have small IT operations compared to the massive hospital-based health systems that typically have EHRs and extensive CDS tools for doctors and nurses. But some behavioral healthcare entities have taken the plunge into CDS technology, and their experiences offer their peers an idea of the challenges and opportunities involved.

Among the fraternity of behavioral healthcare professionals with hands-on experience in implementing CDS systems is Grady Wilkinson. Since 2002, Wilkinson has been president and CEO of Sacred Heart Rehabilitation Center, a behavioral healthcare provider based in Memphis, Michigan, which plans on rolling out a CDS system within the next few months. Previously, Wilkinson was the CEO at Decatur, Illinois-based Heritage Behavioral Health Center, which won the prestigious Davies Award in 2001 for its development of an electronic clinical record.

Among the CDS elements of Heritage's electronic clinical record are prompts for drug-drug interactions/contraindications, as well as decision support prompts linked to its assessment and treatment plan documentation capabilities. For example, clicking a box noting that a patient has suicidal ideation prompts the clinician to perform a suicidal lethality assessment.

In developing CDS systems, Wilkinson has struggled with the use of free text in behavioral healthcare records. “The way we're supposed to document requires a heavy dose of narrative,” he explains. “And one of the things we struggled with at Heritage, and that we're struggling with at Sacred Heart, is moving toward some level of standardization to reduce the amount of free text.”

Wilkinson also cites the large amount of data stored in behavioral health records, and the need to share that data with clinicians at different sites in the community, as other challenges facing the development of CDS tools in the field.

Heritage is not the only behavioral health organization to win a Davies Award for its EHR/CDS efforts. This fall the Center for Behavioral Health (CBH) in Bloomington, Indiana, and the Texas Department of State Health Services (DSHS) also were recognized for their efforts to take operations into the electronic realm (CBH in the Davies Awards’ Organizational category, the same category in which Heritage was recognized, and DSHS in the Public Health category). CBH's CEO, Dennis P. Morrison, PhD, has been an outspoken advocate for behavioral healthcare organizations to embrace EHR and CDS technologies, and in the October 2006 issue of Behavioral Healthcare (page 34) he offers his perspectives on CDS. (CBH's and DSHS's award-winning IT efforts will be detailed in a future issue of Behavioral Healthcare).

Experts familiar with behavioral health IT vendors say progress on CDS technology is being made, although it will take some time to produce truly optimal products for behavioral health professionals. Tom Trabin, PhD, executive director of the Software and Technology Vendors’ Association (SATVA) and a member of the Davies Award Committee, also cites the problem with free text as a major obstacle.

“One of the things we learned in the Davies Award Committee experience is that the most difficult clinical documentation process to automate is free text,” he notes. “And that's one of the last to get automated in the medical arena. It's not as essential as many other elements on the medical side, whereas it's just the opposite in behavioral health.” Dr. Trabin adds, “There are software packages out there that have risen to the challenge, usually with a combination of the developer's package and some degree of customization.”

The good news, industry experts agree, is that the tools behavioral healthcare professionals need most will gradually become better and more available with time.