EMRs BRING ALL OF HEALTHCARE TOGETHER

Behavioral healthcare documentation in electronic medical records (EMRs) poses both challenges as well as opportunities to integrate behavioral healthcare with the overall healthcare delivery system. EMRs offer the ability to provide timely behavioral healthcare information to primary and specialty care physicians that can enhance care coordination. Yet a primary concern is addressing the importance of confidentiality.

This article focuses on two areas. First, we examine the fundamental issues healthcare providers and leaders should consider in determining how behavioral healthcare documentation should be integrated into EMRs. Second, we consider potential strategies to address these issues. Our experience is based on Group Health Cooperative's two-year implementation of an EMR system. Group Health Cooperative is an integrated healthcare system serving nearly 550,000 people in Washington State and Idaho.

Fundamental Issues

The core issue in determining how behavioral healthcare documentation is integrated within the overall EMR is addressing the direction of a healthcare organization as it pertains to balancing the importance of care coordination and confidentiality. Key questions to consider are:

What has been your organization's expe-rience with sharing behavioral healthcare documentation with primary care/specialty care?

How an organization historically has addressed confidentiality/care coordination issues within a paper record system will have a significant influence on how to address these issues within an EMR. Relevant issues include the number of patient complaints regarding specially protected healthcare information (e.g., mental healthcare and chemical dependency) being included in a medical chart, as well as any quality-of-care concerns that have been the result of primary/specialty care providers not being able to have access to behavioral healthcare information.

What is your organization's strategic di-rection regarding the integration of behavioral healthcare and your healthcare delivery system?

If your organization has had a number of strategic initiatives focused on integrating behavioral healthcare into your healthcare delivery system (e.g., depression management in primary care), then it is important that your behavioral healthcare documentation in an EMR be relatively highly integrated within your healthcare system, and that the content is relevant to a broader audience than just behavioral healthcare clinicians.

What are key constituents’ perspectives on confidentiality/care coordination regarding behavioral healthcare documentation within a healthcare system?

Through either focus groups or surveys, determine the perspectives of primary/specialty healthcare providers, behavioral healthcare providers, and patients regarding the inclusion of behavioral healthcare documentation within the overall medical record.

What is the status of behavioral healthcare documentation standards before the EMR implementation?

An EMR increases documentation visibility among various behavioral healthcare providers and primary/specialty healthcare providers. How well the information has been documented in paper records by various behavioral healthcare providers, as well as how that information is shared with primary care providers, will indicate how much leadership direction is needed to develop consistent documentation approaches integral to an EMR.

What is the EMR you are using, or considering, capable of?

EMRs are typically designed for universal sharing among all clinicians. Most EMRs have not been structured to address issues associated with both confidentiality and coordination of care in behavioral health documentation. Your organization will need to address the level of technical support available within your delivery system or with the EMR vendor to do the customization often necessary for behavioral health documentation.

When Group Health reviewed these issues, we found strong interest in both preserving confidentiality and ensuring that information is available to healthcare providers to assist with coordination-of-care issues. We found:

• A strong interest in promoting care coordination between primary care and behavioral healthcare. Primary care doctors had been concerned that they historically had not received enough information regarding behavioral healthcare patients. A number of strategic initiatives had been undertaken to integrate behavioral healthcare with the overall healthcare system.

• Consumers felt it was important for their primary care physicians to be aware of basic information regarding their behavioral healthcare, as well as to preserve the confidentiality of behavioral healthcare documentation. Consumers wanted more personal information to stay within the behavioral healthcare system.

• Behavioral healthcare providers shared similar concerns about the impact of broader sharing of information on the therapeutic relationship. Group Health historically had a separate behavioral healthcare chart with limited information available to the overall healthcare system.

TABLE. Group Health's split-note EMR structure for mental healthcare documentation*

Implementation Strategies

Once you are clear on the overall direction of behavioral healthcare documentation within an EMR, a number of implementation strategies can be taken by answering the following questions:

What behavioral healthcare information should be part of the overall healthcare EMR?

For Group Health, a distinction was made between chemical dependency care and mental healthcare. Federal law 42 CFR Part 2 is explicit that chemical dependency information may not be shared with anyone outside of the chemical dependency program unless in cases of medical emergency or with explicit written authorization. HIPAA and Washington State regulations indicate that mental healthcare information can be shared when clinically needed.

Thus, for chemical dependency care, only medication and laboratory information would be shared, as it was deemed that patient safety could be compromised if medical providers did not have access to that information. A similar assumption is made for medication and lab information as it pertains to mental healthcare. For mental healthcare, information felt to be of most relevance to healthcare providers, as it pertains to coordination of care, would be shared, while more personal information would only be viewable by mental healthcare providers.

Therefore, the EMR has a “split-note structure”: Part of the mental healthcare documentation, the subjective and objective portion (S/O), is only viewable by behavioral healthcare providers. Another part of mental healthcare documentation, the assessment and plan portion (A/P), is viewable by nonbehavioral healthcare prescribers (i.e., primary care and specialty care physicians, nurse practitioners, and physician assistants). The table summarizes the specific content for each part of mental healthcare documentation.

Who should have access to behavioral healthcare information, and how should it be shared?

First, it is important that staff of the chemical dependency and mental healthcare programs be able to access mental healthcare notes. Remember that coordination of mental healthcare also needs to occur within a behavioral healthcare program. For chemical dependency notes, federal regulations indicate that while such notes can be shared among providers within a chemical dependency program, they cannot be viewed by anyone else (including mental healthcare providers) absent patient authorization.

With regards to medication and labs for chemical dependency and mental healthcare, access is to anyone in the healthcare system who currently has access to medication and labs (e.g., RNs). For mental healthcare information seen to be most relevant to medical providers as it pertains to coordination of care (i.e., the diagnosis and treatment plan), access should be to all nonbehavioral healthcare prescribers.

In determining how this information should be shared with other healthcare providers, it is important that the principle of informed consent be addressed with both patients and healthcare providers. It is important that behavioral healthcare providers inform patients about what mental healthcare information is routinely shared with other healthcare providers. For mental healthcare providers, the focus should be on the portion of the note shared with nonbehavioral healthcare prescribers. For chemical dependency providers, the focus is on the note's confidentiality and that only lab and medication information would be shared. If a patient receiving chemical dependency care is uncomfortable with shared lab and meds, or if a patient receiving mental healthcare is uncomfortable with the portion of the mental healthcare note being shared with other healthcare providers, then accommodations should be made to ensure such information is kept confidential unless there is a reasonable concern that overall care could be compromised.

It is necessary to communicate to healthcare providers that access to behavioral healthcare information is on a clinical need-to-know basis (i.e., that in opening and looking at selected behavioral healthcare information, they are doing so to assist with care coordination). EMRs often have a security matrix that can identify which providers can access selected behavioral healthcare information.

What are the adaptive challenges for clinicians and organizations?

Clinicians, particularly behavioral healthcare providers, tend to be more comfortable with language/people-based tasks as compared to computer use. Thus, particular attention needs to be paid to the development of basic computer skills such as typing proficiency and use of electronic shorthand such as “smart phrases”; for example, when a provider types “.prt,” what gets printed in documentation is “patient reports that.” At Group Health, we have found it important to invest in both initial and ongoing training to support clinicians in the development of these computer skills. At the same time, providers can't let the computer get in the way of the relationship in the therapeutic environment. Attention needs to be paid to particular biases behavioral healthcare clinicians might have regarding sharing even limited behavioral healthcare information with healthcare providers.

Healthcare providers might be frustrated with not having access to more behavioral healthcare documentation, but they often are unaware of legal and clinical issues regarding behavioral healthcare information confidentiality. Also, it is challenging for clinicians to think of the computer as an active part of the treatment process (e.g., availability of patient education information) rather than just as a documentation tool.

Organizations have to find the right balance in restraining and permitting behavioral healthcare information to be shared. If staff are too cautious in sharing information, the documentation could be insufficient for care coordination. On the other hand, inadequate attention to confidentiality issues can create too much information sharing, possibly leading to violations of patients’ rights.

How do you define and measure success and improve behavioral healthcare documentation in an EMR?

After you implement an EMR, it is important to know whether your documentation process is addressing the right balance of confidentiality and care coordination. First, establish and measure behavioral healthcare providers’ adherence to documentation standards regarding what information should be limited to just behavioral healthcare providers and what information should be shared with healthcare providers. In addition, an EMR should provide the complete clinical information often found in paper records. Patient satisfaction surveys, as well as feedback from nonbehavioral healthcare prescribers, can help assess the EMR's effectiveness in supporting communication between behavioral and primary healthcare while maintaining confidentiality. In addition, tracking consumer complaints about confidentiality and quality of care can help determine an EMR's success.

We have found that having standardized documentation policies adhering to regulations and built with meaningful professional participation help clarify for clinicians, patients, and organizational leaders the confidentiality/coordination-of-care principles. It is critical to look at this documentation process from a quality-improvement perspective. Use measures and feedback to continually modify your documentation process.

Conclusion

An EMR provides the opportunity for increased standardization and efficiency of not just documentation, but also of how care is provided and delivered. At Group Health, addressing electronic documentation issues has resulted in increased clarification regarding both the importance of confidentiality as it pertains to behavioral healthcare, as well as the importance of behavioral healthcare as part of the overall healthcare system. In fact, primary care physicians are very interested in their patients’ psychosocial aspects, as well as in supporting their behavioral healthcare.

How a behavioral healthcare provider documents care likely represents the type of care provided. Thus, EMR implementation not only is about getting clear about what you want documented, but it is also about providing direction in treatment.

The challenge in an integrated delivery system is to make sure that behavioral healthcare documentation responds not just to what healthcare providers would like to know about behavioral healthcare treatment (i.e., what is the diagnosis and treatment plan), but also what they can do to help reinforce the direction of behavioral healthcare treatment and where to go if they need behavioral healthcare for their patients.

What we have shared represents our initial experience with an EMR, and there likely will continue to be changes in our healthcare system as we learn more about how to address behavioral health documentation in an EMR. We would like to stress the need to pay attention to legislative issues on this subject. Behavioral healthcare advocates and professionals need to make lawmakers aware of necessary changes in behavioral healthcare information that can better support the ultimate objective of reducing the suffering and improving the functioning of individuals with behavioral healthcare disorders. For example, we would advocate federal legislation to amend federal law 42 CFR Part 2 to allow some limited sharing of chemical dependency information with other healthcare providers.

All of the authors are with Group Health Cooperative, headquartered in Seattle.

Bradley Steinfeld, PhD, is Assistant Director of Professional Services, Behavioral Health Services; he is responsible for clinical aspects of the EMR implementation system for behavioral healthcare staff.
Barbara Ekorenrud is Administration and Operations Manager, Behavioral Health Services; she is responsible for administrative aspects of the EMR system for behavioral healthcare staff.
Clayton Gillett is Associate Director of Clinical Informatics; he has administrative responsibility for the EMR system's implementation throughout Group Health.
Michael Quirk, PhD, is Director of Behavioral Health Services; he is responsible for strategic direction as it pertains to the interface of behavioral healthcare information within the EMR.
Ted Eytan, MD, is Medical Director of Clinical Informatics; he has clinical responsibility for the EMR's implementation throughout Group Health.