A universal, simple, portable electronic health record (EHR) is one of the most promising potential benefits of the information age. An ATM card provides standardized access to information on a bank customer's financial accounts; it's no great technologic leap to envision a similar electronic key unlocking access to a patient's medical history. The EHR could provide a single standardized reporting mechanism for third-party payers, offer critical data to emergency room doctors confronted with an unfamiliar patient in crisis, and reduce the likelihood of adverse medication interactions. Above all, the EHR, using current technology, could slash healthcare administration's soaring costs.
The EHR's appeal has brought it to the forefront of healthcare policy. The National Institute of Medicine, the President's New Freedom Commission on Mental Health, and Newt Gingrich's healthcare reform action group all have endorsed the mantra that rapid IT deployment is critical for healthcare quality improvement and cost savings. On April 27, 2004, President Bush issued an executive order calling for a ten-year timeline for the development and implementation of health information technology to help achieve substantial improvements in healthcare safety and efficiency. David J. Brailer, MD, PhD, was appointed the federal government's first national coordinator for health information technology less than a month later.
Private-sector behavioral healthcare has moved rapidly to adapt electronic record keeping to patient billing and service records. Public-sector payers generally have moved more leisurely. However, in September 2005, the U.S. Department of Health and Human Services convened a two-day National Summit on Defining a Strategy for Behavioral Health Information Management and Its Role Within the National Health Information Infrastructure. Unfortunately, the summit's unwieldy name was only too fitting for an implementation process that appears to be cumbersome and weighed down with bureaucratic baggage.
In their meeting presentations, summit participants identified some of the reasons for the slow adoption of electronic records. Claudia Roth, PhD, president and CEO of the Western Psychiatric Institute and Clinic (WPIC) at the University of Pittsburgh Medical Center, related the arrival of health IT at her facility over a four-year period. After unsuccessfully attempting to acquire a commercially available system during the early 1990s, WPIC made a significant investment in developing its own electronic health information system, Clinical Progress Notes. One year later, WPIC abandoned continued development of the Clinical Progress Notes system in favor of purchasing a new system that would incorporate clinicians as system designers. Leaving clinicians out of the development and acquisition process had proven to be an expensive mistake because an EHR deployment's effectiveness depends largely on clinicians' willingness to use the system.
Adoption of a truly universal EHR that includes behavioral healthcare is likely to be even more difficult than the WPIC experience because many behavioral healthcare providers are solo-practice professionals. This is most often the situation in public-sector behavioral healthcare in smaller communities, where therapists generally operate on the basis of individual contracts issued by the local mental health, education, and criminal justice authorities. These solo-practice therapists lack the infrastructure support--and frankly the time--to commit themselves to learning new computer-based health information systems.
Beyond these practical issues, summit attendees recognized the existence of a cultural gap between the clinician's perception of therapy as 'art' and the expectation that an EHR will need standardized definitions that might well produce artificial segmentation of interventions into neat but inaccurate care descriptions. This already has become a problem in efforts to establish uniform billing codes for mental health therapy, in which practices such as peer interventions and family therapies give auditors heartburn as they try to distinguish services for the patient from services for the patient's support system. Summit participants voiced platitudes about the need for 'strong leadership' and 'workforce training on a national scale,' but they ultimately agreed that the only way to overcome clinician prejudices about oversimplification of the description of care in an EHR will be to achieve widespread practical use of a universal record in clinical settings.
Mental health consumers have their own reservations about the deployment of a universal EHR. The summit briefly acknowledged that patients and their families will insist on control over the records' contents, as well as protection against the misuse of information that would become available through the system. Sylvia Caras, a spokesperson for the consumer movement, explained that the fears relate more to the potential for stigmatization of behavioral health patients. 'There is a real concern that an inappropriate diagnosis or inaccurate information could remain in the record for years, without the consumer having any way to edit the misinformation,' she said.
Other attendees added that effective behavioral healthcare requires confidential information about consumers that falls outside of the 'normal' health record, including sexual preferences, financial supports, and experiences with employers and government authorities. Achieving a balance between what therapists need to know and what other healthcare professionals should not learn about behavioral healthcare patients is going to be a serious challenge in implementing a truly universal record.
The challenges confronting a universal EHR may become complicated by the fact that SAMHSA has assumed responsibility for federal leadership in this arena. SAMHSA already has been heavily involved in its own 'universal' behavioral healthcare information system: the National Outcome Measures (NOMs). SAMHSA applies NOMs to behavioral healthcare services in ten domains:
* abstinence
* employment/education
* crime and criminal justice
* stability in housing
* access/capacity
* retention in care
* social connectedness
* consumer perception of care
* cost-effectiveness
* use of evidence-based practices
These domains might be reasonable measures for public-sector care, in which reduction of dependence on taxpayer support is a major issue, but they have much less relevance to the reasons private-sector consumers become patients. For example, the NOMs offer no assessments of therapy's ability to produce satisfying sexual relationships or to help consumers overcome problems of grief that may not directly affect their 'life in the community.' Nevertheless, SAMHSA officials at the summit effectively endorsed the NOMs as the core of a behavioral healthcare EHR.
In truth, SAMHSA's ability to influence public-sector behavioral healthcare is sharply undercut by its relatively minor role in financing direct care. Medicaid and Medicare--financing systems that lie outside of SAMHSA's purview--today fund the vast majority of public-sector behavioral healthcare. The federal Centers for Medicare & Medicaid Services (CMS) maintains electronic records for behavioral healthcare that are far more influential than SAMHSA's NOMs for the simple reason that their use influences the financial viability of thousands of behavioral healthcare providers. The summit paid only minor attention to this issue, perhaps because SAMHSA representatives vastly outnumbered CMS participants. Adoption of a universal EHR undoubtedly will have significant benefits for quality, the dissemination of evidence-based practices, and even the accountability of SAMHSA's grant-funded interventions. Ultimately, however, changes in healthcare in the United States are driven by financial realities and incentives. The federal government's policy of supporting better use of health IT must acknowledge this fundamental principle before it can escape the hothouse atmosphere of summits and seminars.
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MICHAEL J. STOIL, PHD, WASHINGTON EDITOR
