US Pharm. 2013;38(11):60-62.
Behavioral health constitutes an important area of focus
for the application of health information technology (HIT), since as
many as 20% of people are afflicted with a behavioral health issue at
one time or another during their lifetime, and HIT has the potential to
enhance their care.1 Behavioral disorders commonly include
anxiety, depression, and bipolar disorder, and may also include
disturbances of thought such as schizophrenia and psychosis, as well as
borderline personality disorder, panic attacks, and post-traumatic
stress disorder.2 Treatment may be multifactorial, including behavioral therapies, psychotherapy, and pharmacologic therapy.2
many instances, treatment is rendered by clinicians in the primary care
setting, whereas the more complex cases are often treated by behavioral
health specialists in specialized clinics, such as behavioral health
The burden of behavioral health issues may also complicate
the management of chronic medical conditions including diabetes,
cardiovascular disease, and cancer. For example, patients with
behavioral health issues may be less inclined to adhere to chronic
medical regimens for diabetes, hypertension, or lipid management,
leading to excess levels of diabetic or cardiac complications, more
frequent hospitalizations, and more frequent readmissions. Pharmacologic
management is further complicated by variable compliance with regimens,
both for the primary behavioral health issue and also for comorbid
medical conditions, such as diabetes. In addition, some chronic medical
conditions, including diabetes and cardiovascular disease, are
associated with depression, rendering the management of these conditions
highly interdependent.4 To make things even more complex,
some behavioral health medications, such as atypical antipsychotics, may
be a risk factor for or exacerbate an existing underlying metabolic
medical condition. Hence, the management of patients with multiple
comorbidities including a mental health issue and a chronic medical
condition can be extremely challenging to the clinician.
In addition, some patients with behavioral health problems
are un- or under-insured and do not have adequate coverage for their
behavioral illness.5 Such patients are at risk for fragmented
and uncoordinated care. The problem is exacerbated in complex patients
who have two or more chronic conditions; these patients are at great
risk for uncoordinated care of both conditions. Finally, patients with
mental health conditions are at high risk of developing substance abuse
Key Areas for HIT
A variety of HIT tools, including health information
exchange (HIE), mobile health, electronic health records (EHR), personal
health records (PHR), home monitoring systems, decision support
systems, and other technologies, can be applied to meet the challenges
of medication management and adherence, care coordination, and
management of comorbid conditions in behavioral health.7
Medication management is the first key area
where HIT innovations can help improve the quality of care delivery in
the behavioral health domain. Standardized electronic screening tools
can identify and characterize behavioral health issues, especially in
the primary care setting. These tools can also be used to monitor
patient progress in the behavioral health organizational setting.
Clinicians can deploy electronic decision support tools to assist in
medication management; these tools can provide evidence-based
recommendations for pharmacotherapy based on results of screening tests
as well as the presence of underlying medical conditions. Support tools
can also assist in determining when referral for specialty care is
appropriate. Algorithms can help with appropriate selection of specific
agents and can help to avoid unnecessary polypharmacy. Decision support
tools residing on the EHR (including on handheld mobile devices) can
provide recommendations regarding dosing, allergies and adverse
reactions, drug-drug interactions, and drug-laboratory interactions
including hepatic and renal function.8
Furthermore, these tools can access
pharmacy databases to determine whether a particular patient has been
filling prescriptions on a regular basis. Hence, compliance with the
regimen can be monitored. Drug selection can be made patient-specific,
so that drugs that would exacerbate an underlying medical condition,
such as certain atypical antipsychotics, can be avoided in given
patients. Metabolic complications such as weight gain, elevated blood
glucose, and hypertension can be monitored in patients through home
monitoring devices and the data routed back to an analytical engine via a
robust HIE. Vendor solutions, such as home monitoring programs, exist
that can track these parameters and monitor incoming data for adverse
events via an HIE-based rules engine, which analyzes data according to
specific rules set by clinicians.
Mobile devices that can access a powerful HIE with a rules
engine could implement a robust medication management program for
behavioral health. With a mobile device, a primary care or behavioral
health clinician can electronically prescribe, review evidence-based
recommendations about appropriate pharmaceuticals and dosing schedules,
watch patients for metabolic complications, and monitor pharmacy records
for adherence. 9
Care coordination is a second key area for
HIT implementation in the behavioral health arena. At the present time,
there is a paucity of data exchange between primary care clinicians and
behavioral health specialists. Part of the underlying problem is that
these clinicians generally work in very different settings. The stage 2
federal Medicare and Medicaid Meaningful use program now requires
clinicians to demonstrate that they can electronically transmit clinical
data to clinicians in other settings. The Meaningful-Use program was
created under the American Recovery and Reinvestment Act (ARRA) and
provides incentives to eligible providers for the adoption and
meaningful use of certified EHRs.
As the adoption of behavioral health–specific EHRs
improves, there will be more opportunities for behavioral health and
primary care clinicians to exchange data. One possible solution is the
Nationwide Health Information Network Direct Project, sponsored by the
U.S. Department of Health and Human Services Office of the National
Coordinator for Health Information Technology.10 In this
setting, the primary care clinician can send an electronic referral to a
behavioral health specialist using an encrypted secure e-mail over an
HIE. The electronic format will accommodate any type of attachment,
including PDFs, Word documents, radiographic images, and structured data
files that can be incorporated directly into the receiving clinician’s
EHR. In addition, a continuity of care document (CCD) that
provides basic information about the patient, including problem lists,
allergies, medication lists, laboratory data, and other pertinent
information, can be attached.11
Given that there is an acute need to accommodate
behavioral health issues in the Direct Project, there is an opportunity
to enhance the CCD. For example, information about suicide risk, housing
status, substance use, and so on could be incorporated into the CCD
format. Since the Direct Project sends data directly from one provider
to a specified second provider, the document can be compliant with
consent rules. Any protected information about substance abuse cannot be
released or redisclosed without patient consent. Hence, the consent
information can also be incorporated into the CCD.7
Management of comorbid conditions is a third
key area of behavioral health ripe for HIT intervention, in addition to
helping with care coordination and medication management for the
behavioral health issues per se. For example, patients with behavioral
health issues and diabetes are at great risk of having poor diabetic
control. A robust program of home healthcare monitoring along with close
coordination between the primary care clinician and the behavioral
health specialist can help to ensure that the diabetes and associated
cardiac risk factors such as hypertension are well controlled. Daily
home monitoring of blood glucose data, blood pressure, and weight can
detect any adverse trends. These data can be transmitted from the home
monitoring devices to an HIE where an analytic engine continuously
monitors for adverse trends. Any alerts are sent simultaneously to a
care manager at the primary clinician's office, as well as to the
behavioral health provider, so that all providers can reinforce the need
to control these metabolic parameters.
In addition, the clinicians can monitor medication
adherence to antidiabetic, antihyperlipidemic, and antihypertensive
agents. Pertinent laboratory data such as hemoglobin (HbA1c),
electrolytes, blood urea nitrogen (BUN), creatinine, glucose, fasting
lipids, and liver function tests can be collected over the HIE in
structured format so that the results can be directly entered into the
primary care clinician's EHR as well as the behavioral health
clinician’s EHR. In addition, the decision support software in the
analytical engine can flag any adverse trends for clinician review.
While HIT solutions bring great promise, care must be
taken to ensure strict privacy of all records, since there are complex
requirements under both the Health Insurance Portability and
Accountability Act (HIPAA) and Substance Abuse Part 2 laws and
regulations (42 U.S.C. § 290dd-2 and 42 CFR Part 2).12,13 The
substance-abuse regulations apply especially to protected
substance-abuse information and include strict requirements regarding
disclosures and redisclosures. In addition, there are a variety of
state-specific laws and regulations that may apply more broadly to
behavioral health data in electronic systems. This topic has been
reviewed in great detail in an earlier article in this series.5
Barriers to Adoption
Behavioral health providers have traditionally been underutilizers of HIT, with only minimal adoption.14
One barrier to adoption is that the federal Medicare and Medicaid
Meaningful Use incentive program covers only a certain segment of
providers in the behavioral health community. The Medicare program is
implemented under the auspices of the Centers for Medicare and Medicaid
Services (CMS) with input from other federal agencies and offices such
as the Office of the National Coordinator for Health Information
Technology. The Medicaid program is administered by the states with
funding from CMS. Psychiatrists and psychiatric nurse practitioners are
eligible for the Meaningful Use incentive program under the ARRA;
however, other behavioral health providers such as psychologists,
clinical social workers, community mental health centers, and
psychiatric hospitals are not eligible. Legislation to remedy this
situation was introduced in August 2013 by Rep. Tim Murphy (R-PA) and
Rep. Ron Barber (D-AZ). The bill is called the Behavioral Health
Information Technology Act of 2013 (HR 2957), and is pending review in
Congress at the time of this article.15
Another barrier to adoption is that
commercially available EHRs generally lack the logic to implement the
complex consent rules that are required to manage patient consent and to
control re-disclosure of protected substance- abuse treatment
information. Such information needs to be specifically tracked by the
EHR, because once introduced into the EHR system, this protected
information cannot be further disclosed without specific consent.5
Many clinicians who treat patients with behavioral health conditions,
especially those in primary care, are not aware of these complex
regulatory requirements. Furthermore, the rules governing exchange of
this protected information through an HIE are also complex and not
easily implemented.5 There are also myriad state regulations
regarding protected behavioral health information, making it difficult
for vendors to develop a national solution.7
There is an enormous opportunity to adopt HIT tools,
including HIE, mobile health, EHRs, personal health records, home
monitoring systems, decision support systems, and other technologies, to
meet the challenges of medication management and adherence, care
coordination, and management of comorbid conditions in behavioral
health. However, there are still significant policy barriers to adoption
that will need to be overcome in order to move the opportunity to
1. Substance Abuse and Mental Health Services Administration. Mental Health, United States, 2010. HHS Publication No. (SMA) 12-4681. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012.
2. National Alliance on Mental Illness.
What is mental illness: mental illness facts.
www.nami.org/template.cfm?section=about_mental_illness. Accessed Aug 25,
3. New York State Office of Mental
Health. Behavioral Health Organizations Implementation.
www.omh.ny.gov/omhweb/bho/. Accessed October 12, 2013.
4. Egede LE, Zheng D, Simpson K. Comorbid
depression is associated with increased healthcare use and expenditures
in individuals with diabetes. Diabetes Care. 2002:25:464-470.
5. Figge HL. HIT and behavioral health: the challenges of data exchange and privacy. US Pharm. 2012;37(12):HS16-HS18.
6. Martins S, Gorelick D. Conditional
substance abuse and dependence by diagnosis of mood or anxiety disorder
or schizophrenia in the US population. Drug and Alcohol Dependence, 2011;119:28-36.
7. U.S. Department of Health and Human
Services. Office of the National Coordinator for Health Information
Technology, and RTI International. Behavioral health roundtable.
Published September 2012.www.healthit.gov/sites/default/files/bh-roundtable-findings-report_0.pdf. Accessed October 12, 2013.
8. Figge HL. Computerized clinical decision support and drug interaction databases. US Pharm. 2012;37:47-49.
9. New York State Office of Mental
Health. PSYCKES: Psychiatric Clinical Knowledge Enhancement System.
Updated November 8, 2012.
www.omh.ny.gov/omhweb/psyckes/information.html. Accessed October 12,
10. U.S. Department of Health and Human
Services. Office of the National Coordinator for Health Information
Technology. Direct Project.
Accessed October 12, 2013.
11. Health Level Seven International. HL7/ASTM Implementation Guide for CDA® R2—Continuity of Care Document (CCD®) Release 1. www.hl7.org/implement/standards/product_brief.cfm?product_id=6. Accessed October 12, 2013.
12. Figge H. HIPAA: privacy, security, and pharmacy information technology. US Pharm. 2011; 36(11):78-81.
13. U.S. Department of Health and Human
Services. Legal Action Center for the Substance Abuse and Mental Health
Services Administration. Frequently asked questions. Applying the
substance abuse confidentiality regulations to health information
exchange (HIE).1-17. www.samhsa.gov/HealthPrivacy/docs/EHR-FAQs.pdf.
Accessed August 25, 2013.
14. The National Council (2012). HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health: Report on the 2012 National Council Survey.
National Council for Community Behavioral Healthcare.
Accessed October 12, 2013.
15. HIMSS News. New bill would extend EHR
incentives to behavioral health. August 23, 2013.
www.himss.org/News/NewsDetail.aspx?ItemNumber=22026. Accessed October
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