An Inside Look into the Current Partnership Workgroup
COVID-19 anxiety is increasingly part of our everyday lives. The resulting disruptions in daily routines can create or worsen anxiety and raise other mental and behavioral health concerns. In the best of times, behavioral health conditions are often underdiagnosed and undertreated. According to Jetelina et al., every year "26% of the United States population experiences an emotional, mental, or behavioral health problem."1 In addition to the current events triggering these conditions, behavioral health issues can also be associated with chronic medical conditions such as diabetes,2 cardiovascular disease, and substance use disorder (SUD).3
Failure to address behavioral health needs in a coordinated manner can result in conflicting treatments, adverse events, and increased healthcare costs.4 In recent years, "integration" of behavioral health and primary care has emerged as an approach to enhance care coordination and quality. How can technology be used to facilitate such integration and better enable "whole patient" care?
For the past few months, through a joint workgroup, ECRI and the Healthcare Information and Management Systems Society (HIMSS) Electronic Health Record (EHR) Association have been investigating how to use health information technology (IT) and digital tools to facilitate the integration of behavioral health with primary care. The workgroup has identified three areas where technology can enhance integration: screening, documentation, and the sharing of information.
Screening for behavioral health issues (e.g., anxiety, depression, SUD) can be facilitated using technology and related resources. Incorporating screening assessments, making clinical decision support tools available to trigger needed assessments, and ensuring clinical assessments are clearly visible and able to be exchanged among clinical team members are just some of the ways technology can help foster shared responsibilities and integrated practice.
Integration models have been the focus of much study5 over the past several years. At its heart, integrated care requires a team approach. By definition, integrated care is "the care rendered by a practice team of primary care and behavioral health clinicians and staff, working together with patients and families and using a systematic and cost-effective approach to provide patient-centered care that addresses diverse physical health and behavioral health needs."6 Although the ability to view, exchange, and share behavioral health information is dependent on federal and state laws and regulations and system interoperability and configuration, it is also dependent on organizational models of care delivery and healthcare organizations' policies and procedures. Integrated care models can take various forms, but all are designed to improve on models of minimal collaboration or collaboration from a distance, which generally involve separate treatment plans and separate care responsibilities.7
Integration models include close collaboration, colocation, or full integration.7 In each model, clinicians take advantage of shared knowledge and collaborative treatment planning. When behavioral health and primary care providers work closely together, they are better positioned to treat patients' full set of needs than they are treating those needs independently8. Moreover, patients frequently desire care in settings that are comfortable and familiar and often prefer obtaining care in a single setting.
Telehealth and telemedicine options also provide opportunities to meet patients "where they are." This option has gained popularity in recent years; however, with the onset of COVID-19 telehealth/telemedicine has rapidly become a prominent care setting. Federal government restrictions as well as restrictions imposed by HIPAA (the Health Insurance Portability and Accountability Act) and payment restrictions on distance care providers and the tools used for telehealth services have recently been lifted. In less than one week these changes have rapidly facilitated needed care through telehealth, especially using audio/video conferencing tools. Although a variety of care setting selections may offer patients additional options and provide clinicians with opportunities to enhance evidence-based coordinated care, in all settings communication challenges still prevail.
While interoperability seeks to address improvements in the communication and sharing of information, certain EHR/health IT system basics are central and must first be in place before the value of interoperability can be realized. Key elements include incorporating screening; ensuring the ability to document, track, and share relevant information; and supporting communication and exchange of information. These elements are the focus of this unique collaboration between EHRA and safety experts. Their goal is to identify ways technology can be optimized to integrate areas of care (e.g., behavioral health and primary care) that are often treating the same issues (e.g., SUD, depression, anxiety). As focus turns to more cost-effective, patient-centered care, provided in an ever-increasing variety of settings, it becomes paramount that the available tools—in this case, technologies—are used to further this care.
Traditionally, primary care documentation and EHRs were not "tailored to the specific tasks or workflows of behavioral health clinicians embedded in primary care [practices]."1 In some instances, this limitation continues. This lack of tailoring and focused functionality may be due, in part, to differences in documentation between these types of care, the unavailability of shared terminology, the lack of coded fields for sharing information, or the inability to readily "tag" information that triggers outside resources (e.g., reminders, alerts, educational materials). Compounding these concerns is the need to segregate information that requires greater privacy and legal protections.
To address these concerns, the workgroup is evaluating current evidence and bringing together the expertise of a broad group of stakeholders, using virtual collaboration tools, to evaluate these elements by looking at functionalities, data fields, measures, and ways to protect information while exchanging what is necessary. Better use of data elements, reporting functions, and templates along with eliminating the need for double documentation, duplicate data entries, and the scanning of paper documentation are just some areas where technologies can be better utilized.6
The need is increasingly urgent to recognize and provide timely care to those experiencing anxiety, depression, SUDs, or other mental health challenges. It is essential to use and optimize the available technologies to support evaluation, care, treatment, progress monitoring, and exchange of information to ensure that safe and cost-effective care can be provided to patients.
- Jetelina KK, Woodson TT, Gunn R, Muller B, Clark KD, DeVoe JE, Balasubramanian BA, Cohen DJ. Evaluation of an electronic health record (EHR) tool for integrated behavioral health in primary care. J Am Board Fam Med. 2018 Sep-Oct;31(5):712-23. Also available: https://dx.doi.org/10.3122/jabfm.2018.05.180041. PMID: 30201667.
- Bajracharya P, Summers L, Amatya AK, DeBlieck C. Implementation of a depression screening protocol and tools to improve screening for depression in patients with diabetes in the primary care setting. J Nurse Pract. 2016 Nov-Dec;12(10):690-7. Also available: http://dx.doi.org/10.1016/j.nurpra.2016.08.009.
- Wu LT, Payne EH, Roseman K, Kingsbury C, Case A, Nelson C, Lindblad R. Clinical workflow and substance use screening, brief intervention, and referral to treatment data in the electronic health records: a national drug abuse treatment Clinical Trials Network Study. EGEMS (Wash DC). 2019 Aug 1;7(1):35. Also available: https://dx.doi.org/10.5334/egems.293. PMID: 31531381.
- Bierman AS. Preventing and managing multimorbidity by integrating behavioral health and primary care. Health Psychol. 2019 Sep;38(9):851-4. Also available: http://dx.doi.org/10.1037/hea0000787. PMID: 31436466.
- Woodson TT, Gunn R, Clark KD, Balasubramanian BA, Jetelina KK, Muller B, Miller BF, Burdick TE, Cohen DJ. Designing health information technology tools for behavioral health clinicians integrated within a primary care team. J Innov Health Inform. 2018 Oct 31;25(3):158-68. Also available: https://dx.doi.org/10.14236/jhi.v25i3.998. PMID: 30398459.
- Cifuentes M, Davis M, Fernald D, Gunn R, Dickinson P, Cohen DJ. Electronic health record challenges, workarounds, and solutions observed in practices integrating behavioral health and primary care. J Am Board Fam Med. 2015 Sep-Oct;28 Suppl 1:S63-72. Also available: http://dx.doi.org/10.3122/jabfm.2015.S1.150133. PMID: 26359473.
- Lambert K, Fischer-Sanchez D. ASHRM behavioral health care in the ambulatory care/outpatient setting. Chicago (IL): The American Society for Health Care Risk Management (ASHRM) of the American Hospital Association; 2020. 19 p. Also available: https://www.ashrm.org/ashrm-behavioral-health-care-ambulatory-careoutpatient-setting.
- Clarke RM, Jeffrey J, Grossman M, Strouse T, Gitlin M, Skootsky SA. Delivering on accountable care: lessons from a behavioral health program to improve access and outcomes. Health Aff (Millwood). 2016 Aug 1;35(8):1487-93. Also available: https://dx.doi.org/10.1377/hlthaff.2015.1263. PMID: 27503975.