Steps toward standardization in Massachusetts

Massachusetts is ahead of the game when it comes to health care reform, having instituted its own in advance of the federal Affordable Care Act (ACA). The same can be said for the state’s electronic health record (EHR) system – even in behavioral healthcare.

Led by the Association for Behavioral Healthcare (ABH), a trade group representing community-based mental health and addiction treatment organizations in the state, providers and payers are working together with the encouragement of the state to standardize reporting of behavioral healthcare information. But there are many bumps on the road, and it’s not at all clear that all behavioral healthcare providers will actually be up to speed with EHRs by January 2014.

The Massachusetts Standardized Documentation Project (MSDP) is a statewide integrated development effort supporting behavioral healthcare providers at the community level, so that they can integrate their EHR efforts with other electronic health initiatives in the state.

Created by providers, payers, and consumers, the MSDP focuses on federal, state, and accreditation requirements that support services that are recovery-oriented and person-centered. The Massachusetts Department of Mental Health participated in MSDP development, and requires that all CBFS (community based flexible supports) providers use the standardized forms. The ABH runs the program that certifies EHR vendors to work with behavioral healthcare providers in the state (see Figure 1).

Every state’s problem

Systems can’t communicate when everyone enters different information – whether it’s on paper or electronically, explained Ben Jacoby, marketing coordinator for Defran Systems, an EHR provider which is one of the handful certified by the MSDP. The information, and the fields – locations on the electronic form where the information is entered – must be standardized, Jacoby told Behavioral Healthcare. “Standardization is a problem on many levels – among different states, within states among different agencies, and even within agencies themselves,” he said. But without this standardization, there can be no coordination of care.

The best standardization involves using an electronic health record, said Jacoby. Whether the patient goes to his primary care physician, or to a behavioral health agency, the continuity of care document goes with that patient.

One state’s solution

The solution is two-part: standardized forms, which can be on paper, and within EHR systems. Standardizing the language on paper is the first step, but there also has to be a second— adoption of EHR systems. That’s where the MSDP is working hardest to facilitate the transition.

Currently, the MSDP is finalizing its first review of the electronic forms, said Vicker V. DiGravio III, ABH president and CEO. Because payer requirements are not static, the forms have to be continuously updated. Running in parallel to the forms standardization effort is the accreditation process for EHR vendors, also managed by the MSDP. Once accredited by the group, EHR vendors are free to adapt the MSDP forms for operation in their EHR products and to market their products with an MSDP logo.

DiGravio noted that the MSDP’s process is “much less onerous” than the federal certification process for EHR vendors run by the Office of the National Coordinator at the Department of Health and Human Services.

Paper vs. EHR

Ironically, although the MSDP forms were designed to be used within EHRs and are much more cumbersome to use on paper, most providers are using them on paper, said DiGravio.

ABH members are enthusiastic about what the forms can do, especially in how easy the forms make it to comply with payer requirements, but providers can’t take this positive step until they make a much bigger leap to adoption of an EHR system. “A lot of providers are using the forms in paper format because they don’t have the money — the capital, or the reserves — to invest in an EHR system,” DiGravio said.

For IT vendors, this is frustrating since they know that there’s no return on investment for EHRs that aren’t yet implemented. One example: forms in an electronic format can “prepopulate,” meaning much of the information about a patient will be filled in automatically. “This saves administrative costs,” said Jacoby. A range of additional benefits is listed in Figure 2.

Later on, if states like Massachusetts can successfully steer agencies, payers, and providers toward standardization, significant additional savings can be realized. “Everyone needs to be speaking a compatible language,” said Jacoby. “If the electronic systems can’t communicate via that language – if they don’t know which fields to put information in – then the whole purpose of the standardization is lost. You may as well be using paper," he said.

“Our members would love to do it, but they don’t have the money,” said DiGravio. “That’s the challenge for us. If our members are going to stay in business and be part of the health care delivery system, they’ve got to use EHRs. Otherwise, they won’t survive.”

SSTAR’s experience

The experience of one of Massachusetts’ biggest providers indicates that the statewide standardization effort poses big challenges even for agencies that are already steeped in the use of EHR technology. Stanley Street Treatment and Resources (SSTAR), based in Fall River, has not one, but three EHR systems—a legacy of the “siloed” approaches so common in behavioral health until recently.

Though SSTAR has integrated its behavioral health and primary care operations, it remains reliant on one EHR for mental health and addiction (the Substance Abuse Treatment Information System, or SATIS), one for its methadone treatment program (SMART Management’s SMART Software), and one for its primary care program. Despite the availability of all these systems, none of these EHRs supports MSDP’s standardized electronic forms. “So we have some problems in how to coordinate care for those systems,” said SSTAR chief operating officer Pat Ensellem.

 “Many years ago, we bought the system that the Betty Ford Center (Rancho Mirage, Calif.) had been developing and using, with all the levels of care,” she said, referring to SATIS. “It was open source, and you could modify it.”

“But before we had fully implemented it, SATIS was sold to the predecessor of Netsmart, and that organization said they would stop supporting SATIS within six months,” said Ensellem. SSTAR has continued to use SATIS internally, without any external support or updates, for more than six years.

“We held back on buying something new, but we can’t hold back anymore,” she said.
SSTAR uses NexGen as its primary-care EHR, a system that Ensellem said is used by many community health centers. And, while NexGen offers an add-on for behavioral healthcare, she is yet to be convinced that it is the right solution for SSTAR. “NexGen has a big market share, and a constituency to push for requirements that meet the needs of community health centers,” said Ensellem. She worries that the same may not be true for the company’s behavioral healthcare add-on, especially in the area of billing. But, she added, “We haven’t completely closed the door.”

In their search for a solution, Ensellem and her team also have tried to get their systems to work together. At one point, they pulled information from the methadone clinic’s EHR, hoping to add it into the primary care EHR database. “We hired a vendor that was going to build a report for us, but first I needed to get file structure information from NexGen so that the vendor would be able to pull out information in their reports,” she said. But when she learned that the file structure information would entail a separate report from NexGen, she put that effort on hold.

Lessons learned

In light of her organization’s experience with several EHRs, Ensellem offered a few insights about how SSTAR is considering its latest IT challenge.  

She has found that open-source products are relatively inexpensive and allow for modification, but that the marketplace—and with it, the availability of good support for a product — can shift quickly. This has led her to rule out developing the needed behavioral health EHR in-house, as her team once did with SATIS. “You need to have a competent and responsive vendor, and it’s a crap shoot,” Ensellem added. “Whoever you bought it from, it will get bought out, they won’t be there for you, it will be bought out again, and your clout won’t be there.

“What I’ve concluded is that it’s really important to go with someone who’s got a market share already, one that has a track record.” However, Ensellem warns that a healthy dose of caveat emptor is required here as well. While vendors might claim that “everybody” is using their EHR, she stresses that would-be buyers “find out who has successfully billed and gotten paid with it.”

Despite the challenges and the costs of EHRs, which include initial purchase, use license, and local software modifications, Ensellem remains a believer in the technology. “When we implemented SATIS, we had people who never worked a computer and they thought they would have to quit,” she said.

“Once they saw how it helped them – they could be more efficient in their recordkeeping – they saw it was much better.”