Behavioral health is getting a technological facelift at a time when such services have increased in demand. As federal agencies commit $20 million over the next three years to advance health information technology (HIT) in behavioral health care and practice settings, state and private entities are developing their own unique tools to assess trends, enhance clinical decision processes, and improve communication among healthcare professionals.
Health information professionals face new responsibilities and challenges in getting such behavioral health platforms up to speed.
For example, the needs of automated systems involving behavioral health variables differ from the classic medical models that rely on any number of biomarkers, labs, and imaging to inform clinical decision making, says Jeremy Kendrick, MD, an associate professor of psychiatry and provider informaticist for the Huntsman Mental Health Institute and University of Utah Health, whose health system has been working to strengthen its clinical support HIT platforms.
“The relative lack of biomarkers in behavioral health and thus an increased reliance on patient-reported outcomes measures has meant more attention from our patient portal/questionnaire team as well as a bit of ‘thinking outside the traditional medical model box’ from all of our IT partners,” he says.
Historically, behavioral health has lagged behind other areas in adopting health IT capabilities such as data exchange and analytics, reporting, notifications, and clinical decision support.
But COVID-19 created the “twindemic” of COVID and an increase in mental health conditions, says Parinda Khatri, PhD, chief executive officer of Cherokee Health Systems in Knoxville, TN. Now there is an increased recognition that the United States needs to invest in a technology infrastructure for behavioral healthcare, she says.
“We are seeing this devastating aftermath in terms of mental health conditions, and overall poor mental wellbeing across the country,” says Khatri, whose health system has been working for years to build upon a solid behavioral health infrastructure.
An analysis of American Hospital Association survey data by the Office of the National Coordinator for Health Information Technology (ONC) found that 67 percent of psychiatric hospitals had adopted an electronic health record (EHR) certified by the 2015 Edition Health IT Certification Criteria, compared to 86 percent of non-federal, general acute care hospitals. Another ONC analysis of 2020 survey data from the Substance Abuse and Mental Health Services Administration (SAMHSA) revealed that psychiatric hospitals lag even further behind in adoption of interoperability and patient engagement functions.
Behavioral Health Is Difficult To Quantify
Several reasons explain why behavioral health providers are slower to adopt interoperability. They face unique challenges. For example, documentation of encounters is often more difficult to quantify in behavioral health than it is in other healthcare specialties, Khatri says. The challenge is taking a psychotherapy or a medication management note and transforming it into something understandable. It’s not as straightforward as entering lab results, or recording height, weight, and blood pressure, she says.
Funding for interoperable health IT is another problem, says Khatri, who has testified before Congress to invest more in health information technology for behavioral health.
The Health Information Technology for Economic and Clinical Health Act, or HITECH Act, does not include incentives for all health care providers. As a result, some healthcare settings and specialists such as mental health and substance use providers have fallen behind in adopting interoperable health IT, according to a joint statement from Donna Davidson, MPH, policy coordinator in ONC’s Office of Policy, Thomas Novak, ONC’s senior advisor for state policy and Talisha Searcy, MA, MPA, director of SAMHSA’s Office of Performance Analysis and Management, Center for Substance Abuse Treatment.
Behavioral health also suffers from stigma. A lack of understanding about mental health leads to a lack of funding, Khatri says.
However, there are encouraging signs in health IT investments. The Biden-Harris Administration’s Actions to Tackle the Nation’s Mental Health Crisis included a priority on integrating behavioral healthcare into primary care. Recently, the administration announced it was committing $36 million in new funding for grant programs supporting behavioral health services, including $5.4 million for Provider’s Clinical Support System Universities, a program that expands substance use disorder education in health profession programs across the country.
“Over the past few years, as readiness for health IT adoption has expanded to more settings and specialties, the Department of Health and Human Services [HHS] has sought to specifically address behavioral health by including adoption and use in grants and programs that support behavioral health care providers and settings,” according to ONC and SAMHSA.
A new joint ONC/SAMHSA pilot project offers key tools to help advance that integration. Backed by funds from the American Rescue Plan Act of 2021, ONC and SAMHSA are supporting a $20 million initiative to reduce costs and improve functionality of data capture, use, and exchange.
The Behavioral Health Information Technology (BHIT) Initiative will be piloting a series of behavioral health-specific data elements, coordinated through a new United States Core Data for Interoperability (USCDI) domain for behavioral health. The pilots will examine feasibility of the data elements, reliability, validity, data quality, representativeness, and user satisfaction.
USCDI is a standardized set of healthcare data classes and data elements for nationwide, interoperable health information exchange. It contains data elements such as problem list, labs, immunization history, medications, and patient demographics.
The initiative extends USCDI into a new data set, informed by behavioral health experts, as well as patient and clients, and optimized for behavioral health, according to ONC and SAMHSA. The USDI+BH draft data has an open public comment period that runs through May 12.
Pilot participants will be selected from behavioral health providers associated with SAMHSA’s Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUPTRS BG) and Community Mental Health Services Block Grant (MHBG) programs.
They’ll be tasked with applying the USCDI+BH draft data elements in workflows and operations. Recruitment will begin this fall.
The goal is to create a behavioral health information resource that will support implementation of EHRs and other health IT products used by behavioral health providers, making it available to current and future SAMHSA grantees as well as other HHS or state agencies.
Adoption of the USCDI+ BH initiative could support greater data harmonization in the behavioral health provider community by aligning federal programs and potential care settings, according to ONC and SAMHSA. Use of the same data elements across systems may also contribute to improved patient data to support improved treatment and outcomes.
Starting from the Ground Up
Some health systems in the private sector have started their own initiatives to boost health IT support for behavioral health.
Cherokee Health, which sees approximately 67,000 Tennessee patients annually, developed its own behavioral health templates. “The existing behavioral health templates that were in the EHR did not fit us. So, we rebuilt it,” Khatri says.
The goal was to synthesize clinical issues and have them fit within the broader care plan. The previous EHR had hundreds of check boxes, which didn’t tell a story about the patient. There was no clear narrative that said, “Here's the presenting concern. Here's what we're working on, what our goals are, how it impacts the rest of care, and here's who I collaborated with,” Khatri says.
Cherokee created a shared template platform that made it easier for providers to communicate with one another. If someone in primary care asks a question, the shared template enables all physicians on a patient’s care team to see that question. “If I ask someone about substance use disorder or cigarette smoking or alcohol use, the question automatically populates to the other providers,” Khatri says.
This internal tailoring made the EHR more user-friendly and person-centered, whereas before it seemed more pathology centered “and very check-boxy symptom-centered,” she says.
Collaboration with health IT has been essential.
“We have worked with our data analytics team to pull the data from the EHR templates to monitor and report clinical quality, patient safety, and operational metrics to improve access and efficiency,” she says. Dashboards help improve population health and inform decision making about resource allocation, clinical training and support needs, and also assist in value based and/or alternative payment contracts.
The data analytics team also works closely with finance and operations to ensure optimization of Cherokee’s revenue cycle. EHR programmers work with the clinical teams to create appropriate templates, checkboxes, pick lists, and workflows to support clinical care, Khatri says.
The payoff from this collaboration and coordination is improved quality metrics. Cherokee has performed well under the Uniform Data System and Healthcare Effectiveness Data and Information Set or HEDIS programs. “We win quality awards every year. And I know that’s a big part of it is because our teams are working together, the medical and behavioral health teams,” she says.
Collaboration with HI Professionals
Ground up changes like these aren’t easy, Khatri says. For many health systems it’s a logistical burden. “We are small enough that we can make those changes. But when you're a very large system, some of these huge, huge medical centers and hospital systems or practices, it’s hard,” she says. “You've got so many things on the priority list, and behavioral health may be a very small part of your service line.”
For any health system attempting such a revamp, Khatri has the following advice: Build a collaboration between your clinical team and health IT team.
A clinician isn’t always going to understand programming parameters, she says. “I would say, ‘Why can't you just make this connect with this and add this here?’ And they would say, ‘If you do that, that's going to cause us to change 14 different things.’ ”
The key is to learn the other group’s language — and meet on a regular basis to work out areas of friction, she says.
Identifying High-risk Patients
Other private sector innovations are leveraging data platforms to uncover behavioral health trends and foster transparency.
University of Utah Health is piloting an automated system that ensures that any patient who screens positive for depression gets a clinical evaluation and treatment plan. The EHR embeds treatment modules for common mental health conditions and includes a technology that assists with e-consults and other types of provider-to-provider consults.
Sending patient questionnaires to ambulatory patients is one way the health system uses automation. Clinicians gather history for new patients and send rating scales such as the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder 7-item (GAD-7) to patients via their health care patient portal.
“This information goes directly into discrete fields in our electronic health record, taking the data entry burden off the clinician or their support staff,” says Carolyn Klassen, information technology manager and Epic BH specialty liaison with Huntsman Mental Health Institute, a component of University of Utah Health Hospitals and Clinics. This allows the clinician to review the information and make it discussion-ready prior to appointments, optimizing appointment time.
It's also enabled clinicians to pilot approaches for identifying at-risk patients early in their primary care medical home, and providing services for treatment, Kendrick says.
“We are working on Best Practice Advisory alerts for patients who respond to these questions in ways that raise concern for their safety secondary to suicidal ideation,” Kendrick says. Another effort is underway to leverage data on factors such as recent inpatient psychiatric admissions to create alerts and notifications in the charts of at-risk patients.
The health system’s technology professionals, which include analysts, designers, and trainers, work closely with clinical staff to ensure that its EHR works for the behavioral health patient, Klassen. “For instance, assuring pre-visit checklist information and questionnaires are easy to use and completed by the patient saves not only clinician time, but eliminates the need for ‘clerical’ type data entry work in the clinic,” she says.
Clinical staff collaborates with the coding teams to respond to any changes in required documentation. “Getting the information about changes and the updates needed, and completed in a timely manner keeps us in compliance with billing and regulatory requirements,” she says.
On the inpatient side of care, decision support technology assists with medication management such as alerting staff to possible medication administration errors and duplicate order checking. “Having a longitudinal look at the patient’s care in an EHR helps our psychiatrists more easily see what has worked or not worked in the past with a particular patient,” Klassen says. “This information helps the team focus on a course of treatment as quickly as possible.”
The health system has also built standard admission order sets and note templates to help minimize time spent documenting and maximize time spent with the patient.
Mining Data to Show Admission Trends
In 2022, the Virginia Hospital & Healthcare Association (VHHA) launched a public facing interactive tool to provide greater insight about annual behavioral health inpatient admissions.
The Virginia Behavioral Health Inpatient Data Dashboard draws from Virginia Department of Behavioral Health and Developmental Services and VHHA inpatient data to show inpatient psychiatric admissions at both state-run and private sector hospitals. The data also reflects voluntary and involuntary admissions.
Dashboard users can filter the data by year and by admission type to monitor trends. “What the data shows is that year-over-year Virginia private hospitals handle roughly 90 percent of all behavioral health inpatient admissions, including all voluntary behavioral health admissions and the majority of involuntary admissions,” says Julian Walker, VHHA’s vice president of communications. The association represents 111 community, psychiatric, rehabilitation, and specialty hospitals throughout the state.
Development of data tools in health care involves accessing, cleaning, and analyzing voluminous data sets, then creating interactive visualizations accessible to audiences, Walker says. “This often requires considerable effort, analysis, and development,” he adds.
The VHHA team regularly evaluates the tools it produces, including considerations about updates, changes, or even the development of new tools to meet the needs of patients, he says.
Health IT has come a long way from the days of paper documentation and processes, Klassen says.
“It is a very exciting time with respect to electronic health information, and there are some great minds out there making strides in this area every day,” she says. “I am confident there is more development on the horizon to support both patient and clinicians.”
Jennifer Lubell is a freelance healthcare and medical writer based in the Washington, DC, area.
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