C A L I FOR N I A H EALTH C ARE F OU NDATION Behavioral Health IT: Toward Seamless Care for California’s Kids March 2009 Behavioral Health IT: Toward Seamless Care for California’s Kids Prepared for California HealthCare Foundation by Thomas C. Tinstman, M.D. Steven DeMello Health Technology Center March 2009 About the Authors Thomas Tinstman is a senior adviser, and Steven DeMello is executive director and a senior adviser, at the Health Technology Center, a nonprofit research organization and network of experts in San Francisco that specializes in innovations and technologies in health care. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. ©2009 California HealthCare Foundation Contents 2 I. Executive Summary 3 II. Introduction 4 III. Background Information Systems for Behavioral Health Care Behavioral vs. Clinical Systems Impetus for IT Adoption 1 1 IV. Findings Challenges and Opportunities 1 6 V. Conclusion 1 7 Appendices A: Interviewees B: Specifications for IT Vendors 1 9 Endnotes I. Executive Summary A complex network of public and that each county is following an independent path private entities fund and deliver behavioral health toward adoption, that most are implementing a basic care in California. As in many other states, the electronic health record, and that the lengthy process network is characterized by fragmentation and poor entails many difficult challenges, some of which are coordination of services, due in part to reliance unique to behavioral health care. However, this effort on paper records. Information systems tailored also presents many opportunities — among them, specifically to behavioral health care could improve to standardize data and terminologies, build county the efficiency and effectiveness of these services in a collaboration, adopt consumer-centric information number of ways. technologies, establish privacy and security policies, California’s 58 counties, with guidance and develop outcomes measures, set reporting standards, funding from the state, are implementing a variety and share knowledge. of behavioral health information technologies. To get a sense of progress to date and major hurdles, the authors — who focused on care for children and adolescents, given their diverse demographics and needs — reviewed state data and the literature, and interviewed numerous experts. They found 2 | C alifornia H ealth C are F oundation II. Introduction A bout one - third of the nearly 660,000 It focuses on children and adolescents because they California residents who received mental health care are the most diverse segment of the mental health from counties in fiscal 2005 – 06 were children and care population. That diversity, the variety of health adolescents.1 State agencies that fund mental health services children and adolescents receive, and related services for this population, and counties that provide issues arising from a separate but parallel justice them, are in the early stages of a monumental task: system, make information management an especially implementing county-level information systems that complex undertaking. will link behavioral health care records produced The authors reviewed state data and the literature, by a multitude of public and private agencies and and interviewed numerous experts (Appendix A), to organizations. Given that mental health services are better understand the evolution of behavioral health highly fragmented, the goal is to improve access to information systems in California, implementation them, enhance care coordination and continuity, progress at the county level, and the related make evidence-based care easier to deliver, enable challenges and opportunities. outcomes measurement, and manage costs. This report examines the current status, challenges, and opportunities for behavioral health information systems, particularly electronic health records (EHRs) and personal health records (PHRs), that support government-sponsored mental health services for children and adolescents in California.2,3 Behavioral Health IT: Toward Seamless Care for California’s Kids | 3 III. Background B ehavioral health care in C alifornia Counties are charged with meeting the mental is highly decentralized. Under state mandate, the health needs of their residents by developing and 58 counties are responsible for, and have a great deal coordinating comprehensive programs. There are of autonomy in, delivering services. Each renders three basic delivery models: Counties administer services through a Health and Human Services clinics and programs themselves, they contract Agency. Some counties combine mental health with service providers, or they combine these two services and alcohol and drug programs in one approaches — the most common strategy. In the behavioral health agency, while others have separate dual model, the way that a county divides service agencies. The state is responsible for oversight, responsibilities depends on its administrative Medi-Cal reimbursement, and funding from other philosophy and the availability of private contractors. sources. Mental health services covered by Medi-Cal Behavioral health services for children and include hospitalization and institutional treatment, adolescents pose unique challenges: rehabilitation services, targeted case management, medication management, and services provided by The services they need are identified by others, psychiatrists, psychologists, and licensed clinical typically parents or schools; social workers. A third party — a parent, a guardian, or the Figure 1 illustrates the complex web of state — decides if care is necessary and which government entities, subdivisions, and providers at services are appropriate; the state and county levels that interact and play a The family and school have important roles in role. They include mental health providers, social assembling a care plan, and must be included in service and foster care agencies, schools, alcohol and related communications; drug programs, and juvenile justice courts. All are The child or adolescent, parents, school staff, and struggling with three critical needs: service providers all monitor the care plan; To shift from paper records to electronic records Privacy is particularly complex from a legal to deliver and document services, document standpoint, given the number of decisionmakers consumers’ complete care history, and receive and persons employed by others who may have payment; access to confidential information. To link records across service providers to track and coordinate care; Government agencies, providers, payers, and consumers have both unique and common To leverage special computer applications, such as information needs regarding behavioral health decision-support tools and data analysis software, care. But coordinating all of these entities and their to make behavioral health services more effective functions can be very difficult, partly because paper and avoid waste, duplication, and errors. records are scattered and often not readily accessible 4 | C alifornia H ealth C are F oundation Figure 1. Behavioral Health Care in California Governor Judiciary Health and Department of Department of Juvenile Human Services Corrections and Education Courts Agency Rehabilitation Department of Department of Department of Department of Alcohol and Drug Mental Health Social Services Juvenile Justice Programs Child and Family Division County Health and Department of Human Services Corrections and Agency Rehabilitation Department of Department of Department of Department of Alcohol and Drug Mental Health Social Services Juvenile Justice Programs Contracted County Child and Providers Providers Family Division Source: State of California. as consumers move from one point of service to principles and interactive capabilities to facilitate another. information sharing and to empower children and families…. Active patients lead to improved Information Systems for Behavioral outcomes and reduced costs.”4 Health Care These systems could enhance service delivery by Behavioral health information systems are automating the process and integrating consumer “technologies that utilize user-centered design data with knowledge about evidence-based care Behavioral Health IT: Toward Seamless Care for California’s Kids | 5 so that everyone in the care network has access to reduce costs. Planners and policymakers want a important information when and where they need system-centered view, one perhaps defined by the it. There are potential benefits for all stakeholders. organization’s scope or by county or state boundaries. Consumers would benefit from better service and Their focus is likely to be service access, outcomes, improved continuity and quality of care. Providers epidemiology, or efficiency. could offer more efficient and effective care and Good continuity of behavioral health care means have a greater ability to measure quality and collect stakeholders have access to consumers’ history and reimbursement. Payers would benefit from having can create and modify care plans. Statewide, there clear and complete claims. Finally, population are a variety of ways to achieve this technologically. managers, including public health officials, would One is to implement a master information system have access to more accurate and timely aggregate that incorporates all the points of service. Another health information. is to implement multiple but identical systems at all Automation involves using an electronic health service locations, enabling information exchange; record, practice management system, or other when agencies are done with shared files, they technology to collect, process, and store information return them to the home system. A third option is about a consumer during each step of behavioral to develop interoperability standards so different care. At a minimum, this information should include types of information systems are compatible and can the time, date, and location of service and relevant share information. A fourth alternative is PHRs, a clinical data regarding diagnoses or interventions. consumer-centric solution. The consumer — and The electronic information is then available during anyone whom he or she designates — can access this subsequent encounters at other locations to render record online and view or add information. additional services, and also available for purposes A related continuity issue is whether the of billing, managing services, planning, and information system should be interfaced or policymaking. Data must be processed and stored integrated with systems that clinicians use to provide in a way that enables different types of users to view physical health care. The World Health Organization subsets of data related to each of these activities. (WHO) and the United Kingdom — which has more For example, those who provide services to experience with electronic records for behavioral individuals must have a consumer-centered view of health than the United States and also is more the data. They need to see the consumer’s history, advanced than the United States in terms of mental update his or her record, create a new care plan, and health services — recommend integration.5 At a submit orders and requests. Good continuity of care minimum, there should be a continuity-of-care dictates that records be accessible for any type of record accessible to both clinicians and behavioral service and at all service locations. To perform billing, health care providers that includes the consumer’s other users must have an encounter-centered view. history, problem, medication lists, and allergies (to They need to attach any necessary documentation reduce the risk of adverse drug events). and manage the account between claims submission The WHO has developed a general model of a and payment. To manage services, some users must behavioral health information system (Figure 2). The have a service- or facility-centered view of the data model illustrates the various types of services (from so they can improve services, ensure quality, and least-common specialty services at the top of the 6 | C alifornia H ealth C are F oundation Figure 2. A Behavioral Health Information System Model Communicate c o l l ec t Process facil it y V ie w specific data in a and store specified format poi n ts o f ca re Planning Manager Specialty service and policy Psychiatry in Behavioral general hospital health service e n cou n t er V ie w Billing Mental health care and collections with physical health care Informal community care Self-care P erson V ie w Source: Adapted from Mental Health Information Systems. World Health Organization: 2005. pyramid to most-common self-care at the bottom), page), behavioral health information systems should where they are delivered, and the types of data views collect, at the point of service, all data necessary for that facilitate behavioral health care. care and for billing, service management, planning, policymaking, and other tasks. If there are unique Behavioral vs. Clinical Systems data requirements related to payments and/or There are similarities and differences between reports for state and federal agencies, they must be EHRs in the clinical and behavioral arenas. identified before design and implementation. These Major functions such as registration, scheduling, data become the key elements for all electronic documentation, ordering, and billing are the same, transactions. Establishing and managing them over but the systems use different vocabularies — “patient” time is a major challenge; those that billing staff, versus “consumer,” for example — and diagnostic planners, and policymakers focus on may offer little terminologies. In addition, there is much more or no value in terms of service delivery. Therefore, descriptive text in behavioral health care regarding behavioral health information systems must include assessments and interventions, and such care a governance structure — one or more authoritative entails fewer laboratory tests, imaging studies, and persons who take into account the interests of all prescriptions. parties in creating and maintaining the data elements. Based on lessons learned from the adoption of EHRs for clinical health care (see box on next Behavioral Health IT: Toward Seamless Care for California’s Kids | 7 Lessons Learned from Clinical Information Systems In recent decades, information systems for delivering physical health care have evolved from architectures focused on accounting, billing, registration, scheduling, and other provider-centric tasks to architectures that are more patient- centric. Unlike legacy systems, electronic health records (EHRs) capture patient data beginning at the point of care and, in some cases, enable patients to view or add information. EHRs and other technologies, such as personal health records, Web portals, and doctor-patient email, engage patients in their care. There are important lessons from the evolution of clinical information systems for the design, implementation, and operation of behavioral information systems. The design should: • Be customer-focused; • Include transparent data definitions so everyone understands them; • Support standardized, systematically organized medical terminologies that computers can process; • Track workflow beginning at the point of service; • Enable configurations to support role-based work; • Reuse data from the point of service for billing and retrospective reporting for management, planning, and policymaking; • Have an intuitive user interface. Implementation should: • Rely on skilled and experienced project managers; • Begin at the point of service and work toward billing and reporting; • Enable workers to configure the system and redesign workflow based on their needs; • Include training based on knowledge about how adults learn; • Include technical and educational support — and perhaps allow for a larger workforce or smaller caseloads — during the inefficient start-up phase. Operations should include: • Unique identifiers for clients, individual service providers, and facilities; • Adequate “help desk” support; • Software support, content maintenance, and retrospective reporting based on data. Sources: The authors and Stead, W.W., Lin, H.S. (eds). Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Washington, D.C.: National Academies Press, 2009. Impetus for IT Adoption place a greater burden on government-sponsored Several factors are driving the adoption of behavioral health care services. Second, the Centers information systems in both behavioral and clinical for Medicare & Medicaid Services is rapidly moving health care. First, consumers, lawmakers, payers, to require that hospitals report clinical outcomes, and coalitions such as the National Alliance on not just demographic and billing data, to assess the Mental Illness are demanding better care at lower value of the care they provide.6 EHRs can efficiently cost. The deteriorating economic climate could spur capture the kind of data that enable outcomes such demands and, given the rise in unemployment, measurement. It is reasonable to expect that this 8 | C alifornia H ealth C are F oundation value-based approach will ultimately migrate to other which has been distributed. It will yield an estimated areas of federally sponsored health care, including $1 billion in 2008–09.9 behavioral health. The information technology (IT) portion of the In addition to these drivers, impetus for MHSA seeks to: behavioral health technology in California is coming Empower consumers and families by giving them from two major sources: the Mental Health Services tools to securely access health information in “a Act (MHSA) and the California Behavioral Systems wide variety of public and private settings”; Coalition Project. “Modernize and transform clinical and Mental Health Services Act administrative information systems to improve The MHSA (Proposition 63), which state voters quality of care, operational efficiency, and cost- approved in November 2004, directs the California effectiveness”; and Department of Mental Health to “look beyond Develop an integrated information systems ‘business as usual’ to help build a system [in which] infrastructure that enables all counties to access access will be easier, services are more effective, and exchange information securely.10,11 out-of-home and institutional care are reduced, and stigma toward those with severe mental illness or Building on the MHSA, the state Department of serious emotional disturbance no longer exists.”7 The Mental Health established an eight-year technological law imposed a 1 percent tax on Californians earning roadmap for counties that has been guiding them more than $1 million a year to pay for improvements from needs assessment and vendor selection in 2006 in six general areas: capital facilities and technology, to adoption of EHRs integrated with personal health community planning, community services and records by 2014 (Figure 3).12 The law includes support, prevention and early intervention, substantial funding specifically for information innovative programs, and workforce education and systems within the capital facilities and technology training.8 By the end of fiscal 2007 – 08, the tax had category: 10 percent of total revenues in each of the generated more than $4.1 billion, nearly $2 billion of fiscal years 2005 – 06, 2006 – 07, and 2007– 08.13 Figure 3. California’s Behavioral Health Information System Roadmap • Needs Assessment and • EHR “Lite” Clinical Notes • Full EHR RFP/Vendor Selection and History • Infrastructure 2006 2008 2 009 2010 2012 2014 • Practice • Ordering and Viewing/ Fully Integrated • Management E-Prescribing and Lab EHR and PHR Source: California Department of Mental Health. Behavioral Health IT: Toward Seamless Care for California’s Kids | 9 To help counties that had not already selected a vendor, the Department of Mental Health developed a request for proposals based on MHSA guidelines (Appendix B). California Behavioral Systems Coalition Project This project, which began in early 2003 and informally concluded in the spring of 2008, was a joint endeavor by 27 counties to replace legacy information systems primarily designed for practice management and reporting in behavioral health care. Many of these systems are more than 20 years old and comprise outdated hardware and software. Each of 11 large counties designated a project representative, and 16 small counties, working as a single entity, designated one representative. Through collaboration, participating counties sought to reduce the cost of identifying and evaluating information system vendors nationwide and enable individual counties to efficiently select the most suitable system for their needs.14 As originally envisioned, the project was to encompass three phases: requests for information and proposals from vendors, product selection, and collaboration on implementation.15 The coalition completed the first two phases; it may not embark on the third because some counties, as early adopters, are already completing implementation and some are focusing instead on other, non-technological initiatives related to the MHSA. 10 | C alifornia H ealth C are F oundation IV. Findings A lthough there is a wide range of with clinical systems (the Department of Mental published articles on behavioral health care and on Health did not require this as a condition for funding information systems, very few address behavioral under the MHSA). Nor are counties implementing health information systems specifically. However, solutions that would be interoperable with behavioral numerous articles cite the disarray in U.S. health care systems outside their own jurisdictions. mental health services generally — challenges that According to the Department of Mental Health, information systems could potentially help overcome. as of mid-2008: A 2008 report by an American Psychological 69 percent of California’s 58 counties had selected Association task force noted that: a vendor for an EHR or practice management The most salient characteristic of the children’s system; mental health system is, unfortunately, its 80 percent of those that had selected a vendor fragmentation and lack of coordination of chose one of two companies, Netsmart or Anasazi services. In addition to creating considerable Software. The remainder selected another vendor; burden on families, it is inefficient for states, providers, and systems and destructive to the 68 percent of counties with a selected vendor shared goal of service integration. At least six will implement an EHR “lite,” a basic electronic separate sectors or administrative structures record that includes assessment and treatment constitute the “system” serving children with plans, clinical notes, and document images; psychological problems: the mental health sector; education; child welfare, including foster care and 20 percent were implementing a Web-based adoptive services; substance abuse; general health; practice management system that will enable and juvenile justice. These sectors themselves electronic billing (for transactions with both are asymmetrical, in that each offers a range of private contractors and the state) and scheduling; programs with varying levels of restrictiveness and Among those with a selected vendor, 13 percent no consistent standards for access or discharge, had not begun implementation; and sometimes parallel, in that services offered in one sector are not coordinated with services in No counties have progressed to electronic another sector.16 ordering and viewing of laboratory tests and results or to e-prescribing. Few are pursuing a full California is not moving toward a single EHR or an EHR fully integrated with a PHR.17 statewide IT system; rather, each county is taking an independent path in following the state’s roadmap Because the vast majority of counties have to adoption. Furthermore, none of the counties is chosen information systems from Netsmart or implementing a behavioral health information system Anasazi and all are in the early stages of selection that, aside from some billing tasks, will integrate or implementation, this would be a good time to Behavioral Health IT: Toward Seamless Care for California’s Kids | 11 create standards regarding data, identifiers for each Resource Limitations in Small Counties participant in behavioral health care, outcomes Challenge. The population of individual California measurement, and reporting. Such standards would counties ranges from a few thousand to millions. make it easier for counties to share consumers’ core Small counties are at a disadvantage in adopting information. For the counties that have not yet innovative behavioral health information systems selected a product, the state could limit their choice because they have limited funding and resources. to either Netsmart or Anasazi and thereby foster One particularly daunting challenge is recruiting and more uniform adoption. retaining qualified staff to implement and operate such a system. Challenges and Opportunities Interviews with mental health and IT staff at the Opportunity. If small counties collaborate, they may county and state level in California and elsewhere be able to achieve an economy of scale that would revealed numerous challenges (see box) that make purchasing, implementing, and operating a are impeding the adoption of behavioral health behavioral health information system more feasible. information systems. However, lessons learned from For example, New Mexico’s 33 counties are all the implementation of EHRs in clinical settings, the participating in one of 15 local collaborations that author’s own research, and advice from interviewees span government boundaries.18 suggested that there are opportunities to overcome some of these challenges. Scattered Records Challenge. Appropriate and secure stewardship of mental health records is challenging because many Challenges for Behavioral Health IT • Little evidence that EHRs improve outcomes counties deliver mental health services both directly • Resource limitations in small counties and, through contractors, indirectly. Access to • Scattered records consumers’ entire history at the point of service is • Uncoordinated behavioral health and related services essential. Traditionally, a consumer’s record has been • Fragmentation of service delivery (by one or more kept at the most common point of service, such as counties, contractors, or both) a general care clinic, a specialty care clinic, or some • No unique identifiers for consumers and service other service location. This decentralization means providers/locations the record may not be readily accessible to others • Absence of standards for data, data sets, messaging, terminologies, reporting, PHRs who need it. • Pressure to adopt business-oriented rather than care- and consumer-oriented IT Opportunity. Information systems enable ubiquitous • No consensus on privacy/security policies and access to records. If individual counties or county confusion about HIPAA requirements collaborations were to centralize their systems, and if • No standard outcomes measures the state required this, it would further ensure better • Unique but sometimes overlapping data requirements by payers and government agencies continuity of behavioral health services. Alternatives • Workforce resistance include a federation of decentralized electronic tools • Initial decline in productivity during adoption (a model that Kaiser Permanente has instituted in the • Poor knowledge sharing among counties clinical arena), a centralized continuing care record 12 | C alifornia H ealth C are F oundation only, or personal health records. Apparently, no of service for re-use in billing, reporting to state and behavioral health care providers in the United States federal agencies, and other administrative processes. have adopted any of these alternatives. Non-Uniform Identifiers Poor Coordination of Services Challenge. Correct identification of consumers, Challenge. The California Department of Mental families, and service providers and locations is critical Health and many counties have separate departments for maintaining accurate records. Entities in the for mental health services and alcohol and drug behavioral health network use names, numbers, or programs. A significant number of people receiving other disparate means of identification. Meaningful alcohol and drug services also need mental health information sharing will be hampered in the absence services, but the separation of these entities makes it of standard unique identifiers. difficult to coordinate treatment at the two points of care. Opportunity. A universal identification system, preferably at the state level, would be best. It Opportunity. Behavioral health information systems would improve the accuracy of records, billing, and would make it easier to coordinate both types of reporting. At the very least, individual counties need treatment. standard unique identifiers within their jurisdictions. Different Delivery Models No Technological Standards Challenge. The delivery of behavioral health care Challenge. There are currently no requirements for by counties, contractors they designate, or both technological standards related to messaging, data creates inefficiencies, as they typically have different definitions, essential data elements, or terminologies, information systems. If a county requires that which makes it difficult to implement and operate contractors use its system, as Kern and San Diego behavioral health information systems. When the counties do, contractors may have to double-enter state sought information from technology vendors information — first into their own system and about their products, the requests did not specify then into the county’s. But this arrangement also is compatibility with any particular messaging more likely to yield better results than one in which protocol, such as Health Level 7, the most common the county lets contractors manage information one. Information systems that do not support among their multiple service points. The situation the same protocol will not be compatible and, is even more complicated when contractors work after implementation, will require a substantial with multiple counties, which can inhibit access to investment to make them interoperable. Likewise, a services, scheduling, and continuity of care. lack of standard terminologies will make electronic communications and data reconciliation among Opportunity. Behavioral health information systems systems difficult and increase the amount of offer an opportunity to improve access, scheduling, information processing necessary for reporting to and care continuity, and to simplify operations outside agencies. within counties. If appropriately designed, the system would collect consumer data at one time and point Behavioral Health IT: Toward Seamless Care for California’s Kids | 13 Opportunity. Many counties in California are in Security and Privacy Issues the early stages of selecting and implementing a Challenge. Concerns about how best to manage behavioral health information system. Because security and privacy in the electronic era are adopting standards is easier on the front end than common. This is especially true in behavioral health the back end, there is an opportunity for effective care because of the sensitive nature of information. system configuration that will ultimately benefit both Confusion about how the Health Insurance consumers and service providers. Portability and Accountability Act applies only adds to service providers’ anxiety. Together, these factors Business Pressures and aversion to political risk lead to overly restrictive Challenge. Business-oriented practice management, county policies governing information sharing, which including billing, collections, and other in turn compromise continuity of care. administrative tasks, is key for service providers. Indeed, as Figure 3 illustrates, the Department of Opportunity. California could take a leadership role Mental Health’s roadmap considers adoption of in bringing together state and national authorities to an electronic practice management system to be a establish guidelines that would help county managers relatively early goal. Counties might be tempted to create legal and effective security and privacy policies push this organization-centric rather than consumer- oriented to high-quality services. Enforceable, centric function to include reporting about services accountability-based security and privacy techniques, rendered. However, experience in the design and such as electronic logs that automatically track who is implementation of clinical EHRs has shown that accessing information, are generally better than access this approach is more likely to spur resistance among restrictions. EHR users and to reduce efficiency at the point of care. No Outcomes Measures Challenge. Standardized measures for assessing Opportunity. The point of service is where care behavioral health outcomes do not currently exist. begins. It also frames the overall quality of care. Some states, but not California, have made minimal Consumer data collected there is typically sufficient progress in this regard. for billing, reporting, and all other administrative purposes; if they are not sufficient, the data Opportunity. Behavioral health information systems requirements may be inadequate. Knowledge can facilitate outcomes measurement by collecting gained from clinical EHRs could guide the state in data at the point of service; there is no need to encouraging counties to adopt information systems later abstract data from records. But this is possible that focus first on the point of service. In this design, only if the state were to require counties to assess standardized data definitions, data elements, and specified diagnoses at certain times during an episode terminologies make subsequent administrative tasks of care using validated instruments. In addition, easier. counties would have to agree to apply standardized terminologies to all clinical concepts in each instrument, and to reduce the variation in the types of instruments that service providers use. 14 | C alifornia H ealth C are F oundation No Reporting Standards hosted by third parties. The lack of consensus Challenge. Service providers juggle a variety of on privacy policies regarding behavioral health different data standards and definitions when they information about children and adolescents relates to communicate with each other, interact with payers, PHRs as well as other electronic tools. and report to county, state, and federal agencies such as Medi-Cal and Medicare, each of which requests Opportunity. The state and other stakeholders overlapping but unique data sets. Government could work cooperatively to set data standards agencies do not coordinate their efforts or consider and requirements for information ownership and the impact that their reporting requirements have stewardship in a way that fosters adoption of a wide on service providers, including the complexity of array of PHR platforms. data abstraction. They also change the requirements without giving providers ample time to adjust. A lack No Knowledge Sharing of reporting standards means providers must gather Challenge. Counties in the forefront of adopting as much data as possible, some of it superfluous, behavioral health information technology do not at the point of service. These factors will make the have the time or staff to capture, document, and design of electronic interfaces more complex and, in distribute the lessons they have learned — knowledge turn, reduce service efficiency and increase workforce that could be of value to other counties in earlier resistance to behavioral health IT. stages of adoption. Nor, apparently, are there any resources to help counties implement such Opportunity. The state could establish one technology at the point of service. department to serve as a gatekeeper and clearinghouse for all reports that county-level Opportunity. The state could provide technological service providers must submit. A state gatekeeper expertise, equipment, and additional funding to could specify which data must be reported, and help counties meet their IT goal. It could synthesize all reports to any state agency would derive from lessons learned from leading-edge counties and make this information. A proof of benefit would have the information available to others through online to accompany any state request for data or any instruction and electronic libraries. request for a report deviating from the specified data elements. According to interviewees, counties would need at least 18 months to change the core data elements. No PHR Requirements Challenge. Integrating personal health records with behavioral health information systems will be difficult in the absence of PHR standards. Until issues related to data ownership and record stewardship are resolved, service providers will be reluctant to share personal information with PHRs Behavioral Health IT: Toward Seamless Care for California’s Kids | 15 V. Conclusion B ehavioral health care for children Some of the challenges that the state and counties and adolescents in California, as in many other states, face also present opportunities to maximize the faces many serious short-term challenges, among clinical and administrative benefits of IT investments them greater demand for services, more complex and the impact they have on communities. Although health conditions and treatments, and less funding. a collaborative, standards-based approach to IT California’s evolution as a decentralized network of adoption, rather than a county-by-county approach mostly county services fosters locally appropriate without statewide standards, would add complexity solutions, but it also increases the complexity and and cost to the task, it would make successful initial fragmentation of care. Various structural and legal deployment — and continuous improvement over issues exacerbate the situation. time — significantly more likely. Importantly, this Many experts have hailed information technology strategy could also put in place the infrastructure as an important element in transforming health necessary to assess consumer needs and the care generally and mental health care in particular. performance of behavioral health care providers EHRs, Web-based practice management systems, statewide. Such information would support planning PHRs, and other electronic tools geared to behavioral for improved child and adolescent services. health could improve the efficiency, coordination, and continuity of care, as the adoption of EHRs in various clinical settings has demonstrated. California has played a prominent role among states in advancing the use of behavioral health IT, partly due to funding available under the Mental Health Services Act for critical infrastructure and partly to collaboration by counties in the California Behavioral Health Coalition. However, the trajectory of progress to date suggests that implementing multiple, heterogeneous solutions may fall short of leveraging the full potential of technology to improve the quality of care and streamline service delivery. 16 | C alifornia H ealth C are F oundation Appendix A: Interviewees Nina Antoniotti, R.N., Ph.D. David Kears Director Director Marshfield Telehealth Clinic Alameda County Health Care Services Agency Marshfield, Wisconsin San Leandro, California John Bain J.D. Kleinke Chief information officer Chairman and chief executive officer Carlsbad Mental Health Center Omnimedix Institute Carlsbad, New Mexico Portland, Oregon Angelica Bernstein Stephen Mayberg, Ph.D. Account executive Director Anasazi Software California Department of Mental Health Phoenix, Arizona Sacramento, California Janet Biblin, M.P.P., M.P.H. Mark Refowitz Decision support manager Director Alameda County Health Care Services Agency Orange County Department of Mental Health San Leandro, California Santa Ana, California President Alex Briscoe California Mental Health Directors Association Assistant director Sacramento, California Alameda County Health Care Services Agency San Leandro, California Rusty Selix, J.D. Executive director Bruce Bronzan California Mental Health Association Chief executive officer Sacramento, California Trilogy Integrated Resources Executive director San Rafael, California California Council of Community Mental Health Noel Clark Associates Chief executive officer Sacramento, California Carlsbad Mental Health Center Henry Tarke, L.C.S.W. Carlsbad, New Mexico Assistant deputy director Mike Gorodezky, M.S.W., Ph.D. San Diego County Department of Mental Health Consultant San Diego, California BHIS Consulting Kacey Vencill Santa Barbara, California Business analyst Len Gray Sacramento County Information Technology Services Project manager Sacramento, California Sacramento County Information Technology Services Dan Walters Sacramento, California Manager, technical services Tracy Herbert Kern County Department of Mental Health Program manager for research, evaluation, and Bakersfield, California performance outcomes Sacramento County Division of Mental Health Sacramento, California Behavioral Health IT: Toward Seamless Care for California’s Kids | 17 Appendix B: Specifications for IT Vendors In September 2008, the California Department of Mental Health released functional requirements that vendors’ information systems should meet when counties seek proposals. There were three sets of requirements — for consumer and family empowerment, modernization and transformation, and functional needs. Requirements C ONS UMER /FA MILY EM POWER M EN T M OD ERNIZ AT ION A ND T RA NSFORM AT ION FUNCT IONA L NEE D S Provide accurate and current information about a Enable review of treatment and recovery information Infrastructure consumer’s mental health history to the service in a standardized format, allowing the development of provider, the consumer, and the family, when decision-support tools for measuring quality indicators appropriate. (based on national, state, and county standards) to improve care. Promote consumer/family awareness and Enable more efficient communications with Practice management empowerment by emphasizing education and consumers/families and service producers by reducing preventive care, and by providing an interface for the time spent on common administrative procedures. exchanging data with a personal health record. Ensure access to mental health information that Enable integrated outcomes measurements that Clinical data enables consumers to be informed and make assess services and their cost-effectiveness. sensible choices in the mental health system. Promote informed, collaborative decision-making Enable collaborative decision-making with consumers/ Computerized processes for consumers/families and service families and service providers in all aspects of the physician order entry providers. mental health system. Help service providers record and monitor Automate core business functions — billing/claims, Full EHR consumer needs and provide a way to report assessments, workflow, etc. utilized treatments so the data can be used to improve service quality and recovery. Enable consumers to securely view and enter Aid decision-making by providing access to health Full EHR and PHR comments or data in their records, and to share record information where and when users need it and their journey with a designated family member, by incorporating evidence-based decision support. friend, and service provider. Provide complete and accurate health information Give service providers secure, real-time access to that is crucial in reducing medical errors. accurate, consumer-centric clinical information that can be communicated via interoperable behavioral and medical health information systems using standards developed by organizations such as the Certification Commission for Healthcare Information Technology and Health Level 7. Improve care coordination, such as that related to Enable different information systems to share medication history, lab results, and other clinical information on a secure network within and information. between counties, such that counties, contract service providers, hospital emergency departments, laboratories, pharmacies, and consumers/families can all securely access information. Source: CA BH-EHR Request for Information (RFI). California Department of Mental Health: September 17, 2008 (www.dmh.ca.gov/prop_63/mhsa/technology/rfi.asp). 18 | C alifornia H ealth C are F oundation Endnotes 1. These statistics do not include Yolo County, which has 10. CA BH-EHR Request for Information (RFI). California provided data only up to April 2004. Statistics and Data Department of Mental Health: September 17, 2008 Analysis. California Department of Mental Health: 2007 (www.dmh.ca.gov/prop_63/mhsa/technology/rfi.asp). (www.dmh.ca.gov/statistics_and_data_analysis/docs/ 11. Mental Health Services Act Capital Facilities and statewide_production_rpt/csi_annualreport_fy0506_ Technological Needs Component. Enclosure 1. California final_1.pdf). Department of Mental Health: May 2008 2. Altarum. Environmental Scan of the Personal Health Record (www.dmh.ca.gov/prop_63/mhsa/technology/docs/ (PHR) Market. October 2006 (www.hhs.gov/healthit/ cf_and_tn_enclosure1.pdf ). ahic/materials/meeting11/ce/envscan_phrmarket.pdf). 12. CA BH-EHR Request for Information (RFI). California 3. Gearon, C.J. Perspectives on the Future of Personal Health Department of Mental Health: September 17, 2008. Records. California HealthCare Foundation: June 2007 13. Mental Health Services Act. California Department of (www.chcf.org/documents/chronicdisease/phrperspectives. Mental Health (www.dmh.ca.gov/prop_63/mhsa/docs/ pdf ). mental_health_services_act_full_text.pdf). 4. D’Alessandro, D.M., Dosa, N.P. “Empowering children 14. Jarvis, D., Gorodezky, M.J. Phase I Final Report. and families with information technology.” Archives of California Institute of Mental Health, California Pediatrics & Adolescent Medicine 2001;155(10): 1131– 6. Behavioral Systems Coalition: January 2004 5. Mental Health Information Systems. World Health (www.cimh.org/portals/0/documents/specproj/cbs/ Organization: 2005 (www.who.int/mental_health/policy/ cimh-cbs-phaseireport.pdf). mnh_info_sys.pdf). 15. Ibid. 6. Roadmap for Implementing Value Driven Healthcare in the 16. APA Task Force on Evidence-Based Practice for Children Traditional Medicare Fee-for-Service Program. Centers for and Adolescents. Disseminating Evidence-Based Practice for Medicare & Medicaid Services: 2009 Children and Adolescents: A Systems Approach to Enhancing (www.cms.hhs.gov/qualityinitiativesgeninfo/downloads/ Care. American Psychological Association: August 2008 vbproadmap_oea_1-16_508.pdf). (www.apa.org/releases/ebpcareport0608draftfinal.pdf). 7. Vision Statement and Guiding Principles for DMH 17. Conversion to Electronic System. California Department Implementation of the Mental Health Services Act. of Mental Health: July 31, 2008 California Department of Mental Health: February 16, (www.dmh.ca.gov/prop_63/mhsa/technology/docs/ 2005 (www.dmh.ca.gov/prop_63/mhsa/docs/vision_and_ ehr_project/ehrbaselinemap2008-07-31.pdf). guiding_principles_2-16-05.pdf). 18. 2008 Behavioral Health Collaborative Annual Report. 8. Mental Health Services Act. California Department of New Mexico Behavioral Health Collaborative: 2008 Mental Health (www.dmh.ca.gov/prop_63/mhsa/docs/ (www.bhc.state.nm.us/pdf/2008bhcannualreport.pdf ). mental_health_services_act_full_text.pdf). 9. Mayberg, S.W. Mental Health Services Expenditure Report. Fiscal Year 2008-2009. California Department of Mental Health: January 2009 (www.dmh.ca.gov/prop_63/mhsa/ publications/docs/revised_leg_report_format_final_1-7_ %20v11.pdf). Behavioral Health IT: Toward Seamless Care for California’s Kids | 19 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org