Behavioral Health (BH) is a critical component of integrated medical care—particularly for patients with chronic medical conditions. Patients with co-occurring BH diagnoses interact with every level of multi-specialty care, and often have multiple non-interacting treatment plans from different siloed services. Atrius Health has supported a large integrated BH department for over 20 years, and has leveraged the electronic medical record to more fully integrate BH treatment, facilitate communication, and build efficient workflows. Three recent BH department initiatives illustrate the potential for EMR systems to support better integration of BH with medical care.
"When communication and case collaboration take place in a standardized format within the EMR, there is less need for additional time spent on documenting"
Break the Glass: Like most departments in Massachusetts, Atrius Health for over a decade hid BH notes, diagnoses, and problems from medical providers outside of the BH department to protect privacy. This approach negated the value of a shared medical record; a primary care provider had no ability to look into a patient’s diagnosis, let alone treatment progress. In 2015, we carefully introduced a “break the glass” policy under which medical providers could access BH notes by engaging in an audited electronic process to ensure appropriate access. BH patients were uniformly given the option of opting out of the policy, and given referrals for care with services in the local community.
E-consults with Psychiatry: Staffing a department with sufficient psychiatry resources is a challenge. Wait times for BH prescribers at Atrius Health were long and primary care providers (PCPs) struggled to make appropriate prescribing decisions for complex BH patients. To leverage existing psychiatry resources, Atrius Health is experimenting with an e-consult protocol focused on supporting PCPs to build more confidence in their own prescribing practices, while reducing the volume of referrals to BH specialty care.
An e-consult from a PCP flows through Atrius Health’s EMR to a designated psychiatrist, who reviews the information and details a response. This goes immediately back to the PCP, who may take action with greater confidence. The entire e-consult is documented in the record.
Early reports indicate that the system provides a rapid service which allows a psychiatrist to consult on many more cases than they could see in person during the same time period. This results in shorter waiting times for patients, and more appropriate referrals to the BH specialty.
BH Triage System: Another significant challenge in managing BH services relates to matching patients with the right care in a timely manner. Research indicates that the longer patients wait for an appointment, the less likely they are to attend it; and the more severe their problems, the more important it is to match them to the right treatment and providers. In addition, there is a risk that their problems will exacerbate while on a waitlist. Wait times for BH services are notoriously long, and this was the case at Atrius Health, in 2015, when the department redesigned triage.
Referring providers or self-referring patients were asked to detail a patient’s treatment needs and presenting problems in a standardized electronic referral in the EMR, which routed to the BH site geographically closest to the patient’s PCP. Electronic referrals at each service site were stored in a queue, sortable by referral status, urgency, and duration in the queue.
Each referral is reviewed for insurance coverage and, if the insurance product is accepted, licensed therapists on a triage team conduct a chart review and, occasionally, a phone screen with the patient to determine the best care. A weekly triage team meeting matches patients with resources available within the next two weeks to rapidly get them into care. Lastly, medical secretaries outreach to the patients and work to get them scheduled in the recommended treatment course.
At all stages in the process, work is conducted within the EMR and every decision step is documented in a single referral note for easy reference. A monthly audit of the timestamps for each step within the EMR enables fine tuning of the process and identification of bottlenecks. In this case, the health record provided the only consistent repository of all the necessary clinical case data, as well as the communication functioning required to coordinate across sites and service lines. This streamlined process has resulted in a sustained reduction in wait times for psychotherapy from over 60 days, to 10 days.
These and other experiments with the EMR drive home several lessons organizations should consider if they work toward integrated behavioral health models:
• Physical Integration does not Equal Communication:
Even when BH departments are co-located with medical service lines, in-person communication is infrequent and unreliable as a regular source of collaboration. Integration must happen within the EMR, as must the bulk of communication.
• Automatic Documentation:
When communication and case collaboration take place in a standardized format within the EMR, there is less need for additional time spent on documenting. Setting up the right electronic workflows can also make it easier for providers from different service lines to quickly review the status of a referral or treatment course.
• Leverage, Leverage, Leverage: BH departments are often used to being left to their own (often paper-heavy) processes. Integrated BH departments would be wise to study other service lines and learn how they use the EMR, then build processes for the BH department that fit well with existing standard work. The more closely BH EMR processes mirror those in other departments, the more intuitive they will be to collaborating providers.
Communication and collaboration are critical for effective integration of BH services, and the EMR reflects the best opportunity for integrating seamlessly into other service lines’ clinical routines. This may be counterintuitive, as EMRs are often perceived as cold and technical environments, but our experience is the opposite. Smart use of an EMR promotes shared decision-making, supportive practice, and a truly integrated approach to patient-centered care.