Achieving Parity in Healthcare: Integrating Psychiatry into the Healthcare Enterprise

Kennedy Ganti, MDPhysician Informaticist- Cooper Medical Informatics and Care

Delivery InnovationLiezel Granada, MSN

Nursing Informaticist- Cooper Medical Informatics and Care Delivery InnovationFrank Aguilar, MD

Chief Resident – Department of PsychiatryCooper University Health Care

Overview• Learning Objectives

• Identify the communication and coordination gaps between psychiatry and general medicine

• Understand that behavioral health has not been incentivized like general medicine to adopt health IT tools

• Learn how the Patient Protection and Affordable Care Act brings parity to behavioral health and medical care

• Discover how psychiatry is learning the benefits from using a highly connected HER

• Understand the implications of implementing the EHR in Psychiatry towards the goal of integrated behavioral health

• Hear how one academic institution in New Jersey is integrating Psychiatry into general medical care under one EHR platrform.

• History and Barriers of Mental Health Care• Implementation of the EHR in the Psychiatry department• Effects of Implementation through the eyes of a physician

champion

Historical Overview of Behavioral Healthcare from 1800- Present

United for Sight (2012) A Brief History of the US Mental Health System. Last Accessed October 1,2015

> Video available by contacting presenters directly

Population Trends In Behavioral Health

1955 2005 20100

50

100

150

200

250

300

350

400

0

100,000

200,000

300,000

400,000

500,000

600,000

Drop in Number of Psychiatric Beds from 1840-2010

Beds/100,000 population Number of psychiatric beds

Torrey, E Fuller; Entsminger, K et. At “The Shortage of Public Hospital Beds for Mentally Ill Persons” The Treatment Advocacy Center, 2008

Psychiatric Care in the USA: Institutionalization

• Institutionalization of the mentally had been the norm from 1840-1955

• Increasing reports of squalid conditions drove the deinstitutionalization movement from psychiatric hospitals to community care centers

• The advent of Medicaid facilitated the outpatient treatment of the mentally ill starting from the inception of Medicaid in 1965

• Deinstitutionalization drove the development of pharmacotherapies such at chlorpromazine (Thorazine) for schizophrenia in 1954 and imipramine (Tofranil) in 1958

United for Sight (2012) A Brief History of the US Mental Health System. Last Accessed October 1,2015

Barriers to Care• For ambulatory care, Medicaid recipients have

had provisions for psychiatric care• Care for commercially insured patients has been

largely lacking• Starting in 1996 did commercial insurers begin

to receive mandates on covering psychiatric illness on par with medical illness

• The Mental Health Parity and the Mental Health Parity and Addiction Equity Act both mandate increasing regulation on insurance plans to provide equal benefits IF mental health services are offered. THEY DO NOT MANDATE ALL PLANS TO COVER MENTAL ILLNESS CARE BENEFITS !!

SAMHSA (2015, Jun) “Implementation of the Mental Health Parity And Addiction Equity Act (MHPAEA) http://www.samhsa.gov/health-financing/implementation-mental-health-parity-addiction-equity-act Last Accessed October 1,2015

Gaps in Care• Primary care physicians treat 2/3 of all patients

with major depression and generalized anxiety disorder. Diagnoses like bipolar disorder, schizophrenia are generally handled by psychiatric providers (Psychiatrist and psychiatric Advanced Practice Nurses and Physician Assistants).

• Payment for services have often been done as a “carve out”. For many insurers, there is an agreement with a psychiatric benefits manager (Magellan) who manages the benefits and payment of services.

• Consequence- rise of Psychiatry as a “cash only” business

• No need or obligation for Psychiatrists to communicate with Primary Care Physicians

Behavioral Health and Health IT

• The Meaningful Use program has helped partially fund the Health IT revolution in the United States.

• Notable areas of care absent are pediatric care and behavioral health care. These areas were not specified in the original HITECH (Health Information Technology for Economic and Clinical Health) provisions

• From 2012 to 2014, the Office of the National Coordinator has held two separate roundtable discussions on how to extend Health IT to behavioral health

• In 2015, Congressional legislation introduced on how to have “Meaningful Use for Behavioral Health”

Extending Health IT to Behavioral Health: The Cooper Experience

• In order to provide the best care to our patients, we have embraced whole person care in terms of the biopsychosocial model.

• The Department of Psychiatric at Cooper University Health Care is a significantly grant funded department embracing progressive models of whole person care.

• The Department requested and were strong participants in the EHR transformation process

• This is the first step in developing integrated behavior health care.

Implementing the EHR: The power of Nursing Informatics

Project Goals• Implement Epic Ambulatory EHR for

Specialty in support of:– Meaningful use– Improved clinical outcomes– One patient chart across Cooper practices and

hospital

• Improve patient safety by maintaining current patient problem list, medications and allergies

• 100% electronic physician documentation

Project Objectives• Transition from paper records to EHR• Creation of Epic workflows to support the

specialty’s processes• Install infrastructure• Provide training for all staff• Provide support for clinicians and staff

during the change• Minimize Impact on patient care and

office operations

Team• Project Manager – Manages the project processes to ensure

achievement of expected outcome• Epic Team Lead – Schedule and facilitate clinical build work

sessions, provides Epic technical leadership and expertise, develops Epic design solutions, oversees team work effort

• Informatics Lead – Liaison between the clinicians and Epic build team, schedules and facilitates current work flow and process improvement sessions, validates test scenarios

• Epic Builder – Experienced Epic builder 100% committed to project, documents workflows, completes build

• FC Team –TES Front desk implementation, schedule and charge interface planning, testing and activation

• Infrastructure Lead – Responsible for equipping sites for Epic• Training Lead – Develop and deliver specialty specific training• Go-Live support – on site at specialty during the initial

implementation of Epic to help clinicians and staff

Pre-planning• Choosing business owners, provider

champions, and super users• Confirmation of scope• Abstraction criteria • Setting up weekly project meetings (core

team meeting and physician champion meeting)

Planning

• Current workflow analysis • Propose future workflow in epic• Design/Development• Testing (Epic Experience and Validation

Lab)• Training (clinician/front desk training)

Project Plan Timeline (Start)

Execution• UAT sign off• Remind client to reduce schedule• Integrated testing• Technical and Dress Rehearsal• Go live trifold manual

Go-live• Live support – 10 touch points• Command center• Daily status report calls

Maintenance

• Help Desk• Optimizations – monthly physician

champion meeting

The Psychiatrist Is In.. The EHR !!

EHR Benefits in Psychiatry• Ability to read and understand the context

as to why a patient was referred to Psychiatry

• Lab work and Imaging accessible

• Direct communication with other providers

EHR Benefits in Psychiatry

• “Clean up” incorrect existing Psychiatric Diagnosis

• Ability to closely monitor medication Rx

• Find out other providers prescribing controlled substances

EHR Benefits in Psychiatry• Understanding patient’s struggles with

their medical comorbidities

• Obtaining additional Demographic information that can assist in Biopsychosocial formulation

Workflow

• Communication with staff

• Decreased phone time

• Using EPIC with the addition of MA has been very helpful

• Most challenging aspect of incorporating EHR in an ambulatory Psychiatry setting is transitioning Providers

• Especially challenging in Psychiatry– Using a computer during

Patient Encounters has not been common practice historically for Psychiatry compared to other specialties

• Continues to be a work in progress in acclimating providers to new technology

EHR Integrated Behavioral Health

• Collaborative Care• As the Mental Health Consultant

– Provide PCP Brief formulation– Preferred diagnosis / diagnostic impression– Clear point by point treatment plan

• Med Management

EHR Integrated Behavioral Health

• The use of Screening Tools• Development and use of registries • Ability to provide complete care• Providing PCPs the further education on

psychopathology and psychopharmacology

EHR

Questions/Discussion

SOLICITED SOLUTIONS

THANK YOU for attending

our presentation!