1. Overview of Issues: Barriers to Developing EHR in This Field Constance Weisner, DrPH, MSW Jennifer Mertens, PhD Stacy Sterling, MSW, MPH Narrowing the Research-Practice Divide in Evidence- Based Medicine with Adoption of Electronic Health Record Systems: Present and Future Directions National Institute of Drug Abuse Rockville, MD July 13-14, 2009

2. Overview  History  Barriers  Infrastructure  Workforce  Multiple system interaction  Most programs are free-standing-not part of a health plan/using the same EMR  Privacy  Potential

3. National Policy Approach to Behavioral Health Care Crossing the Quality Chasm’s aims, rules, and strategies for redesign should be applied throughout Mental Health/Substance Use health care on a day-to-day operational basis tailored to reflect the characteristics that distinguish Mental Health /Substance Use health care from general health care. Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, DC: National Academies Press; 2006.

4. Six Critical Pathways for Achieving Aims  Effective use of information technology (IT)  News ways of delivering care  Managing the clinical knowledge, skills, and deployment of the workforce  Effective teams and coordination of care across patient conditions, services and settings  Improvements in how quality is measured  Payment methods conducive to good quality

5. M/SU Health Care Compared to General Health Care  Increased stigma, discrimination, & coercion  Patient decision-making ability not as anticipated / supported  Diagnosis more subjective  A less developed quality measurement & improvement infrastructure  More separate care delivery arrangements  Less involvement in the NHII and use of IT  More diverse workforce and more solo practice  Differently structured marketplace

6. Health Plans / Purchasers Recommendations (cont):  Require all contracting organizations to appropriately share patient information;  Provide incentives for the use of electronic health records and other IT;  Use tools to reduce adverse risk selection of M/SU treatment consumers; and  Use measures of quality and coordination of care in purchasing / and oversight.  Associations of purchasers work to reduce variation in reporting / billing requirements.

7. Characteristics of the Addiction Treatment System

8. 13,200 specialty programs in US 31% treat less than 200 patients per year 65% private, not for profit 77% primarily government funded Private insurance <12% Sources – NSSATS, 2002; D’Aunno, 2004 11,600

9. Source 1990 2008 Criminal Justice 38% 61% Employers/EAP 10% 6% Welfare/CPS 8% 14% Hosp/Phys 4% 3% Referral Sources

10. Adolescent Treatment Referral Sources  Parents - 83%  Health care provider - 18%  Legal system - 33% (20% Court Mandated)  Friends - 19%  Mental health providers - 35%  Schools - 13%

11. Phone Interviews With National Sample of 175 Programs regarding personnel, management, information McL, Carise & Kleber JSAT, 2003

12. 12% had closed 13% had changed service operation 31% of the rest had been taken over, usually by MH agencies Program Changes In 16 Months:

13. Counselor turnover 50% per year 50% of directors have been there Less Than 1 year STAFF TURNOVER!

14. Other Staff 54% Had no physician 34% Had P/T physician 39% Had a Nurse < 25% Had a SW or a Psychologist Major professional group - Counselors

15. Modest Computer Availability –Mostly For Administrative Work –80% Had a Computer – 50% had Web Access Still very little computer/software availability for CLINICAL STAFF Information Systems:

16. Multiple System Interaction  Unique to behavioral health care: Most programs are free-standing  collaborative care with:  Health systems  Criminal Justice  Welfare  Important issues for internal EMRs and cross- system communication  Should privacy regulations be the same for each system?  Where the program is embedded?

17. Privacy  “Prevent disclosure of addiction treatment and diagnoses; also create barriers to accessing data and complicate coordination of care, especially with regard to EHRs and electronic networks.”(Institute of Medicine, 2006)

18. Privacy (cont’d)  Continuing Care  Stigma  Variation in clinical and patient concerns

19. Opportunities  Coordination with other systems  Communication with patients  Epidemiologic surveillance  Outcomes monitoring

20. Using Standardized Instruments at Intake and Follow-up

22. Conclusion  Barriers are large and involve characteristics of the treatment system, regulatory issues, workforce issues, and long-term work styles.  Opportunities are increasing and field is ready to grapple with these issues.

23. Thank you!