THE REALITIES OF THE EHR REVOLUTION

When someone receives mental health or substance use care, documentation most frequently is recorded in a paper record. At more advanced sites, an electronic registry is used to collect summary information on each encounter. But all too often, billing records, provider training and employment records, and program descriptions are maintained in separate paper or electronic files. Within this mixed paper and electronic world, quality measurement is extremely difficult, and its direct use for effectively improving care is virtually impossible.

In five to ten years, the goal is to have all healthcare documented in electronic health records (EHRs), which will contain information on health status, insurance coverage, care received, and outcomes. All data applications regarding care will derive from EHRs, including personal health records (PHRs) for care self-management, continuous progress and outcome reports for quality improvement, administrative reports for program managers, and billing records for reimbursement.

Sounds neat, huh? As usual, the devil is lurking in the details. Let's dissect this picture to examine how such changes are likely to occur—and what their consequences are likely to be.

First, EHRs for mental health and substance use care most likely will be made available through general hospitals—likely to be the hubs for regional health information organizations (RHIOs) that permit the shuttling of consumer information among primary care and specialty providers in the network. Thus, EHRs for mental health and substance use consumers essentially will be primary care records adapted to include mental health and substance use information. Other scenarios, such as a separate specialty EHR for mental health and substance use care, are very unlikely because neither of these fields has the necessary electronic infrastructure to support either a specialty EHR or an electronic network on a national basis. This conclusion does not preclude separate specialty EHRs maintained by individual behavioral health provider networks; in fact, excellent examples have been reported previously in this publication.

Second, important data applications likely will involve continuous sampling of EHRs via electronic platforms designed for this purpose. These applications include PHRs, quality improvement tools, billing reports, management reports, and higher-level reports for corporations and state and federal agencies. Each organizational level will maintain electronic platforms to support its applications.

Implementing this radically changed informatics environment requires national leadership to provide a clear vision and to wed information needs to the informatics revolution. The federal Department of Health and Human Services and its agencies, the states, local providers, and private vendors all need to be part of this leadership group. To become part of this revolution, both the mental health and substance use fields must devote financial and political capital to the development of a set of common data standards for use in EHRs and other data applications. The Mental Health Statistics Improvement Program (MHSIP), Decision Support 2000+ (DS2K+), the SAMHSA Forum on Common Performance Measures, and the SAMHSA Treatment Data Standards Committee already have done excellent work in this area. Yet this work needs to be accelerated in the very short term so that our fields have something to put on the table for the coming EHRs.

Both fields must collaborate with the broader healthcare field in the design and implementation of EHRs. This endeavor must span both public and private mental health and substance use services, as well as all levels of government. Currently, such outreach is only in its infancy; efforts need to be accelerated. The Institute of Medicine has identified this as a high priority, and SAMHSA has begun to work with HL7, a key national standards setting group.

Work also must proceed in developing the electronic platforms that will drive data applications at each level. Again, excellent work has been undertaken by SAMHSA's Center for Substance Abuse Prevention in its electronic Data Coordination and Consolidation Center and by SAMHSA's Center for Mental Health Services through the https://www.ds2kplus.org Web site. Obviously, much more needs to be done to develop the specific tools on these platforms so that they have increased utility for consumers, providers, and local program managers. The behavioral healthcare software community must be part of this endeavor in collaboration with software vendors from the healthcare community. Unfortunately, such collaboration is only in its infancy.

We shouldn't forget the data needs at the state and federal levels. Hurricane Katrina provided a very strong wake-up call that more descriptive statistical data are needed at the federal level on mental health and substance use services in each county/parish, including distribution of facilities and beds, types of providers and their skills, and related services. The design of electronic platforms must take into account the need to sample local program and provider files on a continuous basis so that such essential information is readily available during crises. The possibility of pandemic avian influenza, another strong hurricane season, and terrorist attacks underscores the importance of immediate action.

Other data applications, such as national service quality and outcome reports, trend data, policy data, etc., will come directly from the interaction of the electronic platforms with the EHRs and local program and provider files. Within five to ten years, the concept of traditional data collection (e.g., a national survey) will virtually disappear as a result of improved capacity for continuous sampling of these local electronic data sources.

And PHRs will serve as an excellent vehicle for self-care and self-management. Hence, development of electronic platforms that contain consumer portals with credible, high-quality information to guide self-care and self-management is a very high priority. Early examples of this include the Aetna portal for depression and the VA's My HealtheVet. Furthermore, PHRs will provide a mechanism for consumer evaluation of providers. Like the information on quality of care and outcomes in EHRs, consumer evaluations in PHRs will serve as an essential tool for continuous quality improvement.

The future is definitely full of promise. The key elements of our mental health and substance use agenda outlined above are pressing needs that demand immediate attention, effort, and leadership.