Integrated behavioral health and primary care (integration) has been identified as a promising approach to enhancing patient care delivery, safety and quality. Technology tools, including electronic health records (EHRs), telehealth, clinical decision support (CDS), and standards-based interoperability, can enable integration among various disciplines and improve the delivery to more readily addresses patient needs. Reinforcing these opportunities, virtual care and telehealth have dramatically changed care availability and delivery, especially during the COVID-19 pandemic.
Technology-enabled changes have, and will continue to be facilitated by new and revised regulations addressing telehealth, patient access to their electronic data, and interoperability and information blocking. These regulations seek to break down traditional silos of care, enabling clinical information to become more widely available to those who need it.
There are different levels of integration. Each level uses different approaches, from minimal collaboration to full collaboration in a transformed/merged practice. Although the model used does not alter the ability of technology to facilitate integration, it can affect mechanisms and operations and opportunities offered by specific technologies.
During 2020, ECRI’s Partnership for Health IT Patient Safety (Partnership) and the HIMSS Electronic Health Record Association (EHRA) looked closely at using information technology to facilitate integration. Taking a three-pronged approach focused on: (1) screening for behavioral health issues, (2) clinician documentation, and (3) sharing data among clinicians, patients, and authorized parties, the group developed recommendations and strategies for safe use of health IT for integrating these disciplines.
These three interrelated actions can differ in their execution in behavioral health and in primary care. To effectively improve care, information must be captured with vocabularies understood by those who both create and access clinical data and then must be transferred and shared among clinicians and other users. Importantly, tools must be available to assist in the recognition of clinical needs, so care can be initiated, communicated, measured, and shared.
Although needed technologies are increasingly available, they are not universally implemented or adopted in either behavioral health or primary care EHRs. Moreover, behavioral health and primary care clinicians often document information in different ways and with different professional vocabularies, capturing information in different fields, or describing the same data using different terminologies. Sharing between behavioral health and primary care is often limited by available technology, as well as regulations and concerns about whether protected information will remain protected once shared.
The group provided action-oriented safe practice recommendations for EHR and health IT developers, clinicians and healthcare organizations, the government, and other stakeholders to facilitate their efforts to implement and incorporate behavioral health with primary care. The recommendations apply to all levels and models of integrated care, although organizational and technical approaches may vary. The recommendations build on one another as data captured from screening is added to documentation and shared within and across healthcare organizations and with patients. Health IT can facilitate information exchange regardless of which clinician is providing care and plays a role in integrated care regardless of the setting or the level of integration.
Each of the three areas includes specific recommendations:
- Ensure that validated, clinically accepted screening tools are integrated, easily accessible, and readily available in the EHR
- Enable triggers for CDS associated with screening tools to integrate behavioral health and primary care
- Optimize documentation to support integration of behavioral health and primary care
- Enable information sharing across care environments (within organizations, among clinicians in the same system, or across organizations and systems) and with portals, secure messaging, and HIEs
- Enable EHRs to use information in the record to segment patient information for exchange consistent with organizational policies, patient requests, and state and federal laws and regulations
The group also identified potential measures to assess progress, including care and quality measures. Developers and clinicians must work together to ensure that needed information is captured to support such measures.
Developers, healthcare organizations and clinicians face many challenges and uncertainties as a result of the COVID-19 pandemic and associated increases in demand for behavioral health services, new regulations, limited resources, and an increase in telehealth visits. In the face of these pressures, the need to integrate behavioral health with primary care is increasingly important. Health IT has a critical role to play in facilitating safe integration. Optimizing health IT for safe integration is a shared responsibility. Implementing the recommendations will lay a foundation for interoperable optimization of integrated behavioral health with primary care.
Developers can improve integration of behavioral health and primary care by:
- Designing, deploying, and implementing health IT to optimize integration;
- Working with clinicians and healthcare organizations to ensure that each type of functionality is used to its full potential;
- Understanding unmet functionality and process needs; and
- Participating in priority policy and regulatory efforts
At the same time, as developers are being challenged to optimize technology, clinicians, regulators, and patients must also step up and embrace their roles in enabling and improving integrated care. Notably, proposed rules released in December 2020 from the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services Office of Civil Rights (OCR) included requests for information on data segmentation (CMS), how to advance electronic data exchange among behavioral health providers (CMS), and encouraging disclosures of protected health information to help persons experiencing substance use disorder and/or serious mental illness (OCR).