Making EDI standardization a priority in 2012

Behavioral health and social service providers have been dealing with a plethora of non-standard reporting forms and funder requirements for decades. These continue today despite the fact that more providers are adopting electronic health record systems and the need for interoperability with primary care providers is growing.

Why isn’t our field pursuing electronic data interchange (EDI) standardization? 

Before I got involved in the field of behavioral health, I worked in the financial services sector, a field that like so many others embraces technology as a means to enhance efficiency, improve communication, and create new opportunities. Because that field embraced digital communication standards long ago, it is possible for the average American to purchase a share of Toyota on the Tokyo Stock Exchange despite major differences in geography, infrastructure, currency and language. Billions of dollars in trades such as this move markets every day, without paperwork, phone calls, faxes or follow-ups.

All of this enables me to sit down at my computer in New York and trade Toyota stock on the Tokyo exchange within minutes. Afterwards, all the necessary reporting data is automatically submitted to the SEC and Japan’s Financial Services Agency through electronic data interchange.

This brings me to a question:  If we’ve created such efficient international financial markets, why can’t behavioral health and human services funders and providers electronically exchange information within the same state?

Operating in the Stone Age

Many providers and their funders operate in a relative stone age. Many funding agencies require providers to report client information using paper files, PDFs, word documents, or proprietary database systems that don’t support electronic data interchange (EDI-See sidebar “What is Electronic Data Interchange?”).

Among the fraction of proprietary systems that support EDI, there is virtually no standardization. And, since many providers report to multiple funders and regulatory bodies, the lack of standardization often necessitates that electronic data entered into the provider’s system must be reentered, again and again, into other electronic systems that format and store the data differently.

Duplicate data entry and increased administration costs like these are pure waste. And, while tight budgets are the norm for non-profits, the cost of waste like this prevents investment in important, longer term solutions, such as electronic health record (EHR) software.

So, to return to my earlier analogy, if financial regulations required the average consumer buying a share of Toyota to:

1. fax a record of her trade to her broker,
2. email a PDF of the fax confirmation to a regulator in Japan, and,
3. retain a paper copy for herself in case of a surprise SEC audit,

then traders, banks, and businesses would be screaming for relief. In fact, with processes like these, the supremely efficient financial markets that we have today couldn’t exist.

Numerous systems, numerous problems

Examples of non-standard reporting systems and databases can be found almost anywhere in the behavioral health field, including individual government agencies. For example, the New York State Office for People with Developmental Disabilities (OPWDD) operates two disparate databases—the Incident Report and Management Application (IRMA) and CHOICES, an electronic case management system. While IRMA accepts data electronically, the data is in a non-standard format, requiring providers to contract with vendors to create custom electronic formats.

The CHOICES system, a proprietary system developed by OPWDD and launched in 2010, currently has plans to accept data electronically but lacks an exact timeframe. So, while state providers that own an EHR look forward to being able to use EDI, they must wait for a different set of electronic specifications, then develop solutions to meet them, in order to support EDI. This situation begs the question of whether providers are now double-entering data in CHOICES while a labor-saving EDI solution sits on the back burner.

Sadly, administrative processes like these represent “business as usual” for nearly all of America’s behavioral health and social service providers, especially the non-profits. So, why aren’t they in an uproar? It comes down to that old adage—“Don’t bite the hand that feeds you.” Today, as you and your organizations manage complex reporting requirements with antiquated processes, it is no surprise that many of you do not have the time or money to invest in an EHR.

But, even for those who have the funds and make the investment, the complexity of current funding streams and reporting requirements makes it virtually impossible to realize the full value of electronic modernization. Standards are needed to enable the modernization process.

Steps toward standardization

The first step in modernization would involve the development of  universal reporting and data standards. Because our industry’s lack of standardization starts at the top, this is no small task, though the financial industry proved that such standards are possible to achieve decades ago. From the top down, the cascade of non-standardization looks something like this:

1. Disconnected federal agencies, both within and outside of the Department of Health and Human Services (ACF, SAMHSA, HRSA, CDC, HUD, ED) flow diverse funding and reporting requirements downstream.
2. A range of state agencies impose additional reporting requirements and mandate that succeeding agencies or providers report according to their proprietary system requirements.
3. A range of county or local agencies/entities add more reporting requirements and introduce additional proprietary system requirements.

For a provider delivering services across the continuum of care and reporting to multiple entities in each state or county, these requirements are staggering. So many of these reports are nearly identical, asking providers to report what is often the same, or a very similar body of data, again and again, in slightly different ways.

Click the image above to view a diagram that illustrates the "web" of funding streams and reporting requirements for human services providers.

The obstacles posed by the lack of data standardization at the funder level are so pervasive and damaging that in some cases, technological change moves in reverse. In New York for instance, the recently developed New York State Clinical Records Initiative (NYSCRI) requires that providers utilize a specific set of forms, regardless of whether providers have an electronic system in place.

This kind of “standardization” does nothing to help EDI. Instead, it prevents it altogether. A more forward-thinking solution would have been to develop consistent and agreed-upon data requirements first, followed by standard methods for exchanging required data between systems and databases.

Once again, saying these things is easier than doing them; but they are absolutely doable.

A multi-state problem

Some state funders support electronic imports into their reporting databases. However, without nationwide reporting standards, the burden of reorganizing and reformatting the same client data falls to the provider agencies. For large, multi-state providers, this consumes personnel and resource dollars that could better be directed toward serving clients.

A few examples of these state systems include:

• Ohio’s Multi-Agency Community Services Information System (MACSIS), which is an automated payment and management information system for mental health services.
• The North Carolina Consumer Data Warehouse (CDW), which provides information about consumers served through the public mental health, developmental disabilities and social services systems. The data they collect includes demographic, clinical, treatment, service and perception of care information.
• The Iowa Data Repository, which accepts files from providers that cover the following domains: Client, Admission, Service (Encounter), Discharge, and Follow-Up.

These state systems not only collect slightly different combinations of the same information, but also require their own custom electronic formats to be used as well. Sometimes, funders impede their own progress toward standardization by creating their own forms. They do this because the human services industry comprises a range of specific fields: mental health, substance use treatment, child and family services, developmental disabilities and others.

Within each of these fields, funders find that custom forms are easier to complete internally, since standard forms would have to accommodate additional items of client data required by some, but not all, funders. Standard forms would also have to deal with the fact that particular terms might have different definitions across the human services continuum. 

Funder inconvenience is likely the main reason why there is resistance to the adoption of a standard format, such as the Continuity of Care Document (CCD), for sharing client data. But the CCD—or any other standard—makes sense for funders because key elements of an individual’s data—name, name, residence, demographics, and medications, for example—are consistent for all funders regardless of location or type of services received.

Based on this consistency, developing a standard for capturing, storing, reporting, and exchanging client data is the logical, essential first step toward dramatically improved communication between providers, funders, and primary care. 

Thankfully, some in government have taken notice of this need. For instance, the Medicaid Information Technology Architecture (MITA)initiative would develop seamless, integrated systems for communicating across Medicaid programs. This initiative envisions not only vertical data exchange from individual provider organizations to county, state and federal agencies, but also lateral data exchange across state and administrative bodies.

Such standardization and integration are critical for behavioral health in particular, because our consumers so often receive primary care, behavioral, or social services from programs administered or regulated by multiple entities. 

Ultimately, EDI standardization can occur as soon as all parties accept and act upon the fact that it is the only way to achieve real efficiency and lasting improvement. In the meantime, here are a few suggestions on things that all of us could do to advance the cause of electronic standardization and data exchange:

• Government payers, funders and granters must stop spending taxpayer dollars developing systems that require providers to perform duplicate data entry.
• Payers must develop standard formats that allow for routine receipt of electronic data, an effort that closely parallels the federal government’s focus on interoperability within the Meaningful Use program. Whether EDI standards are built upon an existing standard, like the existing CCD, or another standard, standardization must be a higher priority for the industry.
• ONC should broaden the scope of the Meaningful Use Program, extending the reach of today’s Health Information Technology (HIT) effort to encompass all Health and Human Services Information Technology. A change like this would bring the requirements of the Departments of Housing and Urban Development and Education under the standards umbrella as well, ensuring that all of government would use standards that now apply only to HIT.

Behavioral health and human services providers care for many of the most underserved people in our society. And, when one compares the costs these providers bear due to non-standardization with the resources available to support interoperability for primary care providers, it’s no stretch to say that they’re underserved, too.

Only by approaching the issue of data standardization and interchange at all levels—federal, state and local—can we generate a positive change for our industry and ensure that we can continue to secure our nation’s health.

Fran Loshin-Turso is president-elect of the Software and Technology Vendors’ Association (SATVA), a trade group of software companies serving the special needs of behavioral health and human services organizations. Fran is also the president and CEO of Defran Systems, a New York City-based developer and provider of behavioral health and human services software.