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Information Technology
Written by Ted Jackson   
January 2006

Dr. David J. Brailer is an excellent speaker, and his depth of knowledge in medical economics and information technology were certainly evident to all who heard him deliver the lead speech last fall at the National Summit on Defining a Strategy for Behavioral Health Information Management in Washington, DC. Hand-picked by President Bush to lead the charge on health care information technology issues as the National Coordinator for Health Information Technology, Dr. Brailer spoke eloquently on the urgent need to develop a nationwide electronic health record (EHR) technology, painting a picture of big economic benefits for insurance companies and governments flowing from greater efficiency, as well as major improvements in quality and convenience for consumers.

But insofar as Dr. Brailer's comments were to a large extent exclusively focused on IT in the med/surg context, they fell somewhat short of what the audience members came to discuss, which was IT in the behavioral health and substance abuse contexts. "There was indeed some disappointment that Dr. Brailer didn't address the behavioral health side," said Ron Mandersheid, chief of State and Community Systems Development at the Survey and Analysis Branch of the Center for Mental Health Services at SAMHSA, and one of the leading experts on behavioral health and substance abuse IT issues.

Brailer's focus at the Washington conference was not surprising considering the general healthcare marketplace is sized at around $1.9 trillion annually, with behavioral health spending a distant second at $144 billion and substance abuse following even more distantly at an estimated $12 billion. And, in any event, Mandersheid says that behavioral health IT will not develop in isolation from general health IT, nor should it, he believes. "We will take our lead from developments in general health IT, and in that context Dr. Brailer's comments were extremely useful for those assembled in Washington to hear."

When Brailer speaks of EHR technology, as he does often while criss crossing the nation, what he is generally referring to is the development of an electronic medical record containing current and historical patient information, clinical decision support, CDS, which gives clinicians support and guidance for best practices treatment, as well as a central data repository, CDR, where all this information is stored.

And what Brailer means when he talks about a national EHR technology - his National Health Information Network - is that all of the internal EHR systems at all the nation's tens of thousands of hospitals, doctors clinics, mental institutions, community agencies and substance abuse treatment facilities should all be able to talk to one another. This herculean IT systems integration task is known in healthcare IT lingo as interoperability. It is truly the Holy Grail of healthcare IT because without it the massive systemwide savings that are forecast to flow from all the big internal investments by individual institutions will probably never materialize.

Producing Productivity

In areas of the economy other than healthcare, especially in sectors like the securities industry, telecommunications and retail merchandising, there have been massive investments made in IT over the past twenty five years, investments that have helped these industries achieve huge increases in productivity, which in turn have helped drive large increases in productivity in the overall economy. These productivity increases have been one of the chief engines of America's recent high growth, low interest rate era of prosperity.

President Bush, by creating the Office of the National Coordinator for Health Information Technology, is jumping on the bandwagon of healthcare IT advocates like Newt Gingrich and his Center for Health Transformation, an institution whose mission is to create a "21st century intelligent health system" based on electronic digital technology. Advocates like Gingrich argue, and heavily government and corporate funded research institutions like the Rand Corporation write reports purporting to prove, that huge productivity increases like the one's achieved in the industries mentioned above would flow to healthcare upon IT investment by governments and private providers.

But skeptics point out that the benefits accruing from big IT investments - Gingrich's organization is urging the Feds to spend $7 billion annually on healthcare IT - into one of the world's most fragmented and inefficient medical systems might not materialize to the extent predicted, and certainly not as quickly as predicted. The big jumps in productivity seen in the overall U.S. economy since the 1990s came after decades of large IT investments beginning mostly in the 1970s, suggesting, some economists say, that a sort of gestation period was necessary before the IT spending took hold and big productivity improvement benefits could begin to flow. Given that overall healthcare IT is not now even where the general economy was in the 1970s when it comes to IT, it seems perhaps realistic to assume that it might be quite some time before society begins to reap in any substantial way the economic and quality improvement dividends that will flow from its investment in healthcare IT.

The Hyper Complexity Factor

Another factor that will surely slow productivity and quality improvements from the upcoming healthcare IT investment wave has to do with the mind numbing complexity of the healthcare field. The range of functionality that healthcare IT systems must accommodate is likely far, far greater than anything ever attempted by any other single industry, including massively complex ones whose products are also used by consumers almost universally, industries like telecommunications and fi nancial services.

Not only are there a huge range of clinical subspecialities to take into account, everything from med/surg staples like cardiology to much smaller areas like mental health and substance abuse, but also an incredible and unparalleled array of billing, regulatory and privacy protection peculiarities. So when President Bush promised, as part of the creation of the Offi ce of the National Coordinator for Health Information Technology, that we would have a fully interoperable national healthcare IT system within 10 years, his promise was met with some skepticism. (From non-vendors, of course.)

But even the skeptics have kept their doubts relatively quiet. And maybe that's because, despite the huge obstacles and the likely lengthy nature of the project, the skeptics suspect that a national healthcare IT system, with record portability and true interoperability, could perhaps represent the best chance we have of affecting a meaningful and deep transformation of the unwieldy behemoth that is the U.S. healthcare system.

Jump Starting Change

Among the leading advocates within the behavioral health and substance abuse arenas of this viewpoint is SAMHSA’s Ron Mandersheid. But Mandersheid, and top addiction industry IT vendor CEOs like Netsmart's Jim Conway and Sequest's Bill Connors, caution that IT is certainly no panacea. They all say that IT's transformative potential will always be limited if it is unaccompanied by institutional and industry-wide efforts that support the cultural changes needed to ensure the success of IT installations.

It was to move forward such efforts, as well as to get the ball rolling on developing industry IT standards, that dozens of addiction and behavioral health executives and clinicians gathered last fall in Washington for a conference sponsored by SAMHSA and the Software and Technology Vendors Association, SATVA, a group of software vendors who specialize in serving the substance abuse and behavioral health industries. Ably led by Tom Trabin, SATVA's executive director, the National Summit on Defining a Strategy for Behavioral Health Information Management and It's Role within the Nationwide Health Information Infrastructure had a defi nite air of urgency about it. And although many participants seemed somewhat daunted by the enormity of task they faced in the coming years, they all seemed well aware that the benefi ts fl owing from their collective effort could prove very substantial. With the billions saved from implementation of effective clinical and administrative IT systems, better and more widespread addiction and mental health services might be delivered.

In its paper, Information Technology and Information Management in Behavioral Health: A Vision for the Future, SATVA points out that most of the national policy and standard setting work has so far been focused on med/surg. And while much of the range of services in behavioral health and substance abuse falls comfortably into the medical model, according to the SATVA paper there are also many services delivered in substance abuse and behavioral health that fall outside the medical model. These include special education components, services in non-traditional settings, services by consumers and services by lay persons.

Because of these services that fall outside the traditional medical model, SATVA says that there is a significant difference in the IT needs of a substance abuse or behavioral health organization and a provider of physical health services. SATVA says that the services that fall outside the traditional medical settings and models give rise to immensely complex billing issues as substance abuse and behavioral health providers struggle to get monies due them by an often bewildering array of public and private payors.

Because the complexity of billing, reimbursement and regulatory-required reporting is quite extensive and labor intensive, substance abuse and behavioral health organizations, especially those that rely on public funding, have tended to put their primary IT efforts toward the demanding business of getting paid. The result has been a relative lack of focus by substance abuse and mental health players on the use of IT to improve addiction treatment and behavioral health for consumers. SATVA believes that if the percentage of IT dollars that is now focused on billing, reimbursement and regulatory reporting could be reduced and a portion of that savings redirected toward improving clinical processes by the use of IT, the substance abuse and behavioral health industries very well might much more quickly be able to realize their goals of improving quality of care for consumers, with the related result of improving outcomes.

And while much of the range of services in behavioral health and substance abuse falls comfortably into the medical model, according to the SATVA paper there are also many services delivered in substance abuse and behavioral health that fall outside the medical model. These include special education components, services in non-traditional settings, services by consumers and services by lay persons.

Because of these services that fall outside the traditional medical model, SATVA says that there is a significant difference in the IT needs of a substance abuse or behavioral health organization and a provider of physical health services. SATVA says that the services that fall outside the traditional medical settings and models give rise to immensely complex billing issues as substance abuse and behavioral health providers struggle to get monies due them by an often bewildering array of public and private payors. Because the complexity of billing, reimbursement and regulatory-required reporting is quite extensive and labor intensive, substance abuse and behavioral health organizations, especially those that rely on public funding, have tended to put their primary IT efforts toward the demanding business of getting paid. The result has been a relative lack of focus by substance abuse and mental health players on the use of IT to improve addiction treatment and behavioral health for consumers. SATVA believes that if the percentage of IT dollars that is now focused on billing, reimbursement and regulatory reporting could be reduced and a portion of that savings redirected toward improving clinical processes by the use of IT, the substance abuse and behavioral health industries very well might much more quickly be able to realize their goals of improving quality of care for consumers, with the related result of improving outcomes.

Treatment's Digital Divide

In a speech delivered at the SATVA conference, the Treatment Research Institute's Deni Carise talked about the preliminary research findings from a study of the basic infrastructure of hundreds of treatment programs throughout the nation. Carise's speech laid out a picture of an overall addiction treatment infrastructure in no way capable of bringing the "new medications, new therapies and new multifocal interventions into the treatment field" that were recently recommended by the National Institutes of Health.

The Treatment Research Institute and Center for Drug Abuse Research study cited by Carise - entitled The National Addiction Treatment Infrastructure: Can it Support The Public's Demand for Quality Care - also described an addiction treatment IT infrastructure woefully inadequate to support efforts to improve clinical care. The study confirmed SATVA's position that much of the substance abuse industry's IT efforts so far have concentrated on helping with the never ending struggle to get paid, with relatively few resources left over for clinicians. According to the report, the U.S. is "choking" on the myriad data collection requirements of regulatory and payor entities, while "starving" for data that is useful in clinical decision making or for improving and streamlining clinical processes.

On the issue of access to IT systems at addiction treatment centers, Carise believes that there has been improvement since the 1990s. "It's better than it was," she says. "But it's still not very good." According to the report, over 80 percent of treatment programs surveyed had some type of administrative information system dedicated to billing and administrative record keeping. With respect to clinical systems, the study found that 30 percent of programs, mostly those operating within the context of some larger health system, had access to some sort of clinical system.

The remaining 70 percent of programs had virtually no access to IT systems for their clinical staff. Of the 70 percent, 20 percent had no access at all, while the remaining 50 percent had at least one computer for clinical staff. But even when computers were available to these 50 percent, there was virtually no availability of clinical management software for treatment planning, patient management, adjunctive service referral or discharge planning. Out of all the programs surveyed, only three programs had what could be termed as highly integrated clinical information systems for use by a majority of the staff.

All this stands in sharp contrast to the IT goings on in the moneyed side of the treatment business, where players like CRC Health Group, Hazelden, Caron Foundation and many others have been pouring substantial resources into IT systems, both administrative and clinical, over the past ten years. These IT efforts have been ongoing despite the fi nancial uncertainty surrounding the advent of managed care since the early 1990s.

In fact, business has been booming for IT vendors focused on providing systems to these types of players, with companies like Sequest Technologies registering powerful growth rates. The market has been so strong that room is being provided for new players like Sigmund Software, which last year signed a big contract with Caron Foundation.

Apart from administrative purposes, investments are being made by these higher end institutions for the express purpose of improving clinical processes and quality of care. Toward that end, CRC Health Group signed what is probably the biggest IT deal in the private side of the business in 2004 with Qualifacts Systems of Nashville. The contract calls for Qualifacts to provide IT services to CRC as an applications service provider, meaning that the entire system is operated and managed by Qualifacts, with CRC employees accessing the system via the Internet.

Speaking to Treatment Magazine last summer, CRC CEO Barry Karlin outlined his rationale for the multi-million dollar IT investment: "We believe our long term survival depends very much on delivering a very high quality level of care. Our investment in IT frees up the clinician to spend more time treating the patient. It's just that simple."

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