carepaths^TM

Can a psychotherapists survive without an EHR?

The adoption rate of EHR in medical practices is expected to accelerate in this country as the government begins providing financial incentives for adoption. But psychologists and social workers are not eligible for these incentives, so can’t they just continue with paper documentation? For most psychologists and clinical social workers, the short answer is no. The answer is no because EHRs are becoming the way providers communicate with each other to coordinate care and refer. The government incentives come with standards for EHRs that facilitate the exchange of clinical information that will become the preferred way of making referrals.

Some background. The last few years has witnessed a dramatic increase in the adoption and implementation ofElectronic Health Records (EHRs) by America’s medical practitioners. It is believed that within the next five years EHRs will be as common in medicine as the stethoscope, the blood pressure monitor, the MRI and other core tools. This rapid adoption of EHRs is being spurred on by the Hitech Act of 2009 which incentivizes practitioners through bonus payments (and later penalties) to adopt federally certified EHRs. The federal certification is called ONC (Office of the National Coordinator for Health Information Technology) of the US Department of of Health and Human Services. ONC certification insures that EHRs are in compliance with the standards and certification criteria of Centers for Medicare and Medicaid Services (CMS.)

Eligible providers (MDs including psychiatrists, nurse practitioners in some states) can receive bonus money from medicaid and medicare by using a certified EHR. They can also avoid a penalty that for non-use which will kick in in 2015 for medicare reimbursement.

Psychologists and other non-medical mental health providers have not been designated by the Hitech act as eligible professionals and so are not eligible for bonus payments. Even so, psychologists, according to Maureen Testoni, JD of the American Psychological Association, “will be impacted by the shift in general record keeping practices across the healthcare industry,” … (and)… “at some point in the future… will be compelled to demonstrate similar progress in order to do business with physicians and hospitals.”

It should be pointed out that most psychologists and clinical social workers, even had the Hitech Act included them as EPs, would only benefit if their practices include a substantial number of medicaid and/or medicare patients.

ONC implementation specifications and certification criteria assure that “certified EHRs” have core features covering interoperability, functionality, utility, and security of health IT. The feature that is most critical to practitioners is interoperability– that is, the ability to share clinical information automatically and in real time. Initially, ONC calls for EHRs to share clinical summaries that include problem lists (diagnoses), medications, and lab test results. It is expected that the amount of information shared will increase over time.

EHRs, then, create the medical equivalent of a grid or network over which clinical information is shared with other users. Being on the grid puts the clinician on the virtual health care team. Any medical referral source–Primary Care Physician, Pediatrician, or Specialist is unlikely to refer to a clinician who can not receive clinical summaries and, who can not, in turn, transmit clinical findings to the referring physician in the standard format used by the rest of the industry.

Interoperability will improve mental health patient care by providing an electronic means for the coordination of care. Psychologists who use a certified EHR will have access to problems lists, as well as medication and lab information. This will enable psychologists with psychopharmacology expertise to make medication recommendations and monitor for side effects. The presence of a psychologist on the patient care team will improve the accuracy of diagnoses and the timeliness of care.

EHRs are the way that integrated care will be realized in the 21st century. However, if psychologists and other non-medical mental health professionals do not use them, not only will individual practitioners be hurt, but so too will the field of psychotherapy as a whole. Specifically, it is likely that the mental health field will become increasing driven by psychopharmacologic treatment. It is of interest, for instance, that ONC quality criterion for depression, measures the percent of patients with a new diagnosis of depression who receive psychopharmacologic treatment within 12 weeks of diagnosis. CMS quality initiatives in the past (see PSQR) used a different criterion: either the percent of newly depressed patients on medication or the percent in psychotherapy. Given the evidence for the efficacy of psychotherapy as a first line treatment of depression, dropping psychotherapy from the quality menu could spell a further erosion of the range of treatments available to patients seeking mental health treatment. More ominously, referral patterns will likely be impacted by quality measure criteria: for example, PCPs who use the depression quality measure will be incented to refer to clinicians who prescribe because doing so will enable them to meet the quality standard for depression whereas a referral to a non-prescribing psychologist will not.

The case for EHRs in the age of the Internet is a strong one. Such features as online scheduling, account setup, self-help, bill pay, access to clinical records, etc will enhance the efficiency and convenience of practice. But what is most important for mental health clinicians is that they get on the clinical team. To do that they will need an ONC certified EHR.