EHR Limitations in Practices Integrating Behavioral Health and Primary Care Maribel CIfuentes, RN, BSN, Deputy Director, Advancing Care Together, Sr. Program Officer, The Colorado Health Foundation Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # G3b October 16, 2015

Acknowledgements Melinda Davis, PhD Doug Fernald, MA Rose Gunn, MA Perry Dickinson, MD Deborah Cohen, PhD Larry Green, MD Emma Gilchrist, MA Stephanie Kirchner, MSPH

Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Learning Objectives At the conclusion of this session, the participant will be able to: Describe common EHR limitations in practices integrating behavioral health and primary care List workarounds practices commonly use Discuss changes in EHRs needed to enable integration and steps practices can take to facilitate their work

Bibliography / Reference 1. Cifuentes M, Davis M, Gunn R, Fernald D, Dickinson WP, Cohen D. Electronic health record challenges, workarounds, and solutions observed in practices integrating behavioral health and primary care. J Am Board Fam Med 2015;28:S63–S Samal L, Hasan O, Venkatesh AK, Volk LA, Bates DW. Health information technology to support care coordination and care transitions: Data needs, capabilities, technical and organizational barriers, and approaches to improvement. National Quality Forum, Available from: Accessed April 22, O'Malley AS, Draper K, Gourevitch R, et al. Electronic health records and support for primary care teamwork. J Am Med Inform Assoc 2015;22:426– Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood) 2010;29:614– Dorr D, Bonner LM, Cohen AN, et al. Informatics systems to promote improved care for chronic illness: A literature review. J Am Med Inform Assoc 2007;14:156–63.

Advancing Care Together (ACT): 5-year program, funded by The Colorado Health Foundation Mission – Discover practical models to integrate mental health, substance use, and primary care services for people with emotional & behavioral problems Goals – Identify and test promising demonstrations – Evaluate process and outcomes [learning evaluation] – Disseminate lessons learned Background

Embedded evaluation led by OHSU and UTH team Learning evaluation aims: – Examine process of implementing interventions and identify cross-project lessons – Examine the effectiveness of interventions on clinical care outcomes, utilization and costs Observational cross-case comparative study – 11 diverse practices in Colorado (8 PC, 3 CMHCs) Mixed methods data analysis – Survey data, text data – Grounded theory approach, multiple immersion- crystallization cycles to identify themes ACT Evaluation

1. Document and track relevant behavioral health or physical health information across time, settings, and members of integrated care teams – Lack of templates and structured data fields to find, track, extract relevant integrated care data 2. Communicate and coordinate care among members of integrated care teams – shared care plans, progress notes, hand offs 3. Exchange information with tablet devices and other EHRs – Tablets used for screening Results: EHR challenges

Double documentation and duplicate data entry Scanning and transporting paper documents Reliance on patient or clinician recall for inaccessible EHR information Use of freestanding tracking systems Results: Common Workarounds

5 Concepts that Shape Integrated Care 1. Integration REACH 2. Continuum of care pathways across severity of illness 3. Patient transitions 4. Location of the integration workforce 5. Mental model for integration Cohen DJ, Balasubramanian BA, Davis M, et al. Understanding care integration from the ground up: five organizing constructs that shape integrated practices. J Am Board Fam Med 2015;28:S7–S20.

5 Concepts that Shape Integrated Care 1. Integration REACH – EHRs not designed to capture integration REACH (various levels) – Manual tracking needed (freestanding spreadsheet) – Systematic screening (EHR & tablets lack interoperability/duplicate data entry) – REACH data information used for evaluation and QI

5 Concepts that Shape Integrated Care 2. Continuum of care pathways across severity of illness – EHRs not able to track patients/data longitudinally – Referrals outside the practice (specialty MH) – EHRs lack of interoperability Systems lacked ability to communicate, exchange data, and use the information that has been exchanged meaningfully (Faxing and scanning patient records)

5 Concepts that Shape Integrated Care 3. Patient transitions – Team member communication/coordination is key – Documentation of warm handoffs, referrals often lacking – Progress notes (BH clinicians often lacking entirely/ usually narrative note, free text) – Access to actionable needed information at the point of care sometimes lacking

“ I just finished meeting with a family for an intake appointment for a 7 year-old boy. I had spoken to (Dr. X) briefly about the referral a few weeks ago but a lot of days and nights and patients have passed by since then. I wasn ’ t able to remember the specifics about…the referral. The family was fuzzy about why they were here. Since I don ’ t have access to the primary care record (from the exam room), I couldn ’ t access (Dr. X ’ s) notes about the referral. I remembered that they had attempted to complete a Vanderbilt Rating Scale but I didn ’ t have access to that. I went to do the releases of information…the family said they already did them with (Dr. X), but they weren ’ t in the electronic document library that I have access to, so I had them do them again. ” Practice Example

5 Concepts that Shape Integrated Care 4. Location of the integration workforce – Close physical proximity important to foster team communication and care coordination – Important to overcome EHR limitations (relying on team members to fill-in information gaps)

5 Concepts that Shape Integrated Care 5. Mental model for integration – Use of 2 or more EHRs problematic in reinforcing a shared mental model of integration – Restricted access to necessary data may communicate that a shift in thinking has not yet been fully adopted - “ my patient ” and “ your patient ” vs. “ our patient ”

Factors that facilitated use of existing EHRs for the delivery of integrated care: a single, unified, EHR system close physical proximity of team members dedicated resources to customize EHRs (templates, structured data fields, upgrades, EHR unification) Lessons Learned

Substantial EHR data collection and use challenges remain unresolved Use of workarounds further burdens practices providers and patients Permanent solutions are needed and will require – financial support – EHR products designed to optimize integration – cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters, and workforce educators Conclusions

Resources 7

Question & Answer Maribel Cifuentes Advancing Care Together JABFM supplement, Advancing Care Together by Integrating Primary Care and Behavioral Health _ 1?etoc

Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!

Practice 18 integrated a physician assistant and medical assistant from a partnering FQHC into a community mental health center (CMHC) to provide on-site primary care. The CMHC and FQHC used two different EHRs that were not interoperable. To overcome this limitation, a care coordinator that had access to both EHRs facilitated communication and exchange of needed information between medical and mental health clinicians and staff. The care coordinator printed daily appointment lists for staff to check-in patients coming in for integrated care visits, and also printed medication lists from the mental health and primary care EHRs that were used by the physician assistant to review and manually update medications on paper. Medication changes and updates were later scanned into the primary care EHR at the FQHC and also manually entered into the mental health EHR at the CMHC. Practice Example