Series 1: Meaningful Use for Behavioral Health Providers

PowerPoint Presentation

Series 1: Meaningful Use for Behavioral Health Providers9/2013From the CIHS Video Series Ten Minutes at a Time

Module 6: Using the EHR as an Effective Tool in Meaningful Use

Welcome to the SAMHSA-HRSA Center for Integrated Health Solutions video series Ten Minutes at a Time- This comprehensive information system on how to meet the standards for Meaningful Use and how to successfully implement an Electronic Health Record is organized into brief, convenient modules targeted to behavioral health providers. This is Series 1 Meaningful Use for Behavioral Health Providers Module 6 Using the EHR as an Effective Tool in Meaningful Use. The goal of this module is to provide you with the information you need to fully utilize the EHR to support the implementation of Meaningful Use.1Outline

The certified EHR is a tool for achieving Meaningful Use not the final goal

Patient engagement is central to successfully achieving Meaningful Use goals and objectivesOverview of 3 Core and 4 Menu Objectives that support patient engagement and better communication

How implementing Meaningful Use is likely to affect the way that clinicians use the EHR to engage patients and how the EHR can be effectively used in the treatment setting

Patient engagement is central to successfully achieving Meaningful Use and the EHR can either support this engagement, or become a barrier to it. We will begin by pointing out the Core and Menu Objectives related to patient engagement. Then we will examine ways to strike a balance between clinician interaction with a patient and using the EHR, including what the research data tell us about patient perceptions and responses to the EHR.

2Core Objectives - Patient CommunicationCore Objective 12: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request. http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/electronic-copy-of-health-information Core Objective 13: Provide clinical summaries [after visit summaries] for patients for each office visit http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/clinical-summaries Core Objective 15: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilitieshttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/protect-electronic-health-information

Core Objective 12 requires that more than 50% of the patient panel receive an electronic copy of their patient information on request. Information may be withheld from this record in accordance with the HIPAA Privacy Rule. information itself must be human readable and the media could be any electronic form such as patient portal, CD, USB or thumb drive, etc., but providers are expected to make reasonable accommodations for patient preference as outlined in federal statute. A reasonable, cost-based fee for a copy of the individuals health information is allowed. Core Objective 13 provides a patient with relevant and actionable information and instructions. It often contains a large data set so the Objective requirements should be considered carefully. This clinical summary can also be used by the behavioral health provider who is responding to a referral, to close the loop by communicating the results to the referral source. Core Objective 15 ensures privacy and security of health information, including information in electronic health records (EHR), a key component to building the trust required to realize the potential benefits of sharing patient information. If individuals and other participants in a network lack trust in electronic exchange of information due to perceived or actual risks to privacy and accuracy, it may affect their willingness to disclose necessary health information and could have life-threatening consequences.

Click this link for more information on Core Objective 12: http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/electronic-copy-of-health-information Click this link for more information on Core Objective 13: http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/clinical-summaries Click this link for more information on Core Objective 15: http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/protect-electronic-health-information3Menu Objectives - Patient CommunicationMenu Objective 4: Send reminders to patients per patient preference for preventive/follow-up care (per HIPAA Privacy and Security 45 CFR 164.522(b) http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-reminders Menu Objective 5: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP.http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-electronic-access Menu Objective 6: Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate.http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-education-resources

Menu Objective 4 considers patient reminders. To many this means we are focused on managing appointments. But patient reminders also include alerts for upcoming necessary tests, preventative services, and other care. The reminder should accommodate reasonable requests for format and frequency, and the provider can reference the measure specifications and the HIPAA Privacy and Security Rule for guidance. Menu Objective 5 requires online electronic access through either a patient portal or personal health record (PHR). However, a provider may decide that electronic access to a portal or PHR is not the best forum to communicate some types of results. Within the confines of laws governing patient access to their medical records, the rule of thumb is to defer to the professionals judgment as to whether or not information should be withheld in anticipation of an actual encounter between the provider and the patient.Menu Objective 6 provides educational information specific to the individual patient does not require the use of any specific media so the patient-specific resources can be provided in any format that is appropriate for the patient. This represents a clear opportunity to engage the patient in commitment to wellness-oriented treatment plan goals.

Click this link for more information about Menu Objective 4: http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-reminders

Click this link for more information about Menu Objective 5: http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-electronic-access

Click this link for more information about Menu Objective 6: http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-education-resources

4Using the EHRS During Patient Encounters Clinicians already have varying communication styles independent of the EHR, that influence how the EHR is used Information focus position at the computer, use of computer guided questions, data orientation to problemsInterpersonal focus led by patients narrative, positioned away from the computerBridging style - combination of both information and interpersonal focus

Reference Ventres, et al., Family Medicine, 2005:37(4):276-281

Clinicians have varying styles of communication that occur along a continuum. On one end of the continuum the provider is focused on collecting and interpreting patient information. This supports good data but does not support good communication. At the other end is an interpersonal focus, where the encounter is driven exclusively by the patients narrative and not by data or the requirements to record critical information. This may support good communication in the moment, but it does not provide good data and does not support communication with other providers or the patient over a period of time. It is essential to find a style of communicating that bridges these different areas of focus. 5Gaining InsightBaseline communication skills, positive and negative, are amplified when the EHRS is in the room with the patient and care giver, and being used for concurrent documentationReference - Frankel et al., Journal of General Internal Medicine 2005;20:677-682

Is the clinician aware of their current practice style?Are they aware of how it impacts their use of the EHRS?Amount of time looking at the screenImpact on patient engagementDo they go to the computer or to the patient first?How much time is spent looking at the screen? Inversely proportional to patient engagement (average is 24% of encounter time)

Reference - Shackak, A., & Reis, J., Evaluation and Clinical Practice 2009;15:641-649)

Using an EHR actually seems to amplify the clinicians focus. So as with most change management efforts, it is critical to begin with a baseline of understanding. First, what are the clinicians perceptions of their current practice style and second, do they align with observation of what actually happens? If an EHR is in use, are they aware of the impact of using the EHR on their style? The ideal balance seems to be to spend about 25% of the encounter time looking at the computer and the rest working directly with the patient (Shackak, A., et al., 2009). 6Practice ConsiderationsDont let the EHRS set the agenda engage patient before going to the computer in the roomLook at the patient (move away from the computer, take hands off keyboard and mouse)Templates use close-ended questions, preventing communication of emotion as well as data. Dont let them drive the entire information gathering processTell the patient what you are doing as you do itPoint to the screenInvolve patients in the documentation processKnow when to stop typing

It is easy to allow the EHR to guide the entire encounter, so it is a good idea to engage the patient before you go to the computer. When you converse with the patient, is can be helpful to sometimes break all connection with the computer since it gives some reassurance that the encounter is not just about getting answers to questions. Encourage patient understanding by letting them know what you are doing in the computer as you are doing it and use the screen to illustrate important points such as test results that are color coded to indicate an out of range score. When feasible, you can engage the patient in the documentation process. This can be especially effective with substance use disorder patients since it promotes ownership of the treatment plan. Above all, know when to stop typing and start listening more closely. Many of our patients have disorders that already make communication quite difficult. There will always be times when you will need to focus 100% of your attention on interacting with the patient but this should not become a reason to abandon the effort entirely. 7SummaryMeaningful Use demands patient involvement in their own care. This is a critical piece in the evolution of health careIn fact, for Stage 1 Meaningful Use, there are 7 Core and Menu Objectives that drive this involvementCommunication tools in the EHR such as the Clinical Summary can be used to support patient involvement The EHR itself can be enlisted to support better communication and to build trust Providers should be aware of their style of communicating and how the EHR amplifies this styleThe next step is to find a balance that supports the use of the EHR as an adjunct to treatment

So, here are the important things to keep in mind. As always, Meaningful Use Objectives are easier to attain when they are considered as an inter-related set of activities that support and complement each other, not treated as a checklist of accomplishments. Patient engagement and communication is a core value in Meaningful Use, and we reviewed the Objectives that are most directly concerned with this. How information is collected and communicated matters, so there needs to be a balance between collecting information and attending directly to the patient. Seating arrangements that support the patients view of the computer screen are recommended, especially in the integration of primary and behavioral health care.8We Have Solutions for Integrating Primary and Behavioral Healthcare

Contact CIHS for all types of primary and behavioral health care integration technical assistance and training needs

1701 K Street NW, Ste 400 Washington DC 20006

Web: www.integration.samhsa.govEmail:[email protected]:202-684-7457

Prepared and presented by Colleen ODonnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions

Our thanks go to SAMHSA and to HRSA for providing support to the Center for Integrated Health Solutions (CIHS) for this and many other forms of training and technical assistance related to the integration of primary and behavioral health care. Please visit our web site at www.integration.samhsa.gov, email us at [email protected], or just pick up the phone and give us a call at 202-684-7457.

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