Goal 6: Technology Is Used to Access Mental Health Care and Information

Recommendations

6.1 Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations. 6.2 Develop and implement integrated electronic health record and personal health information systems.

Understanding the Goal

Mental Health Care Lags in Using Technology

Perhaps the most important medical advance of the 21st century will be the application of information technology to health care - allowing all segments of the health system to interact seamlessly and facilitate safe, high-quality care for consumers. An integrated information technology and communications infrastructure is critical to achieving the five preceding goals and transforming mental health care in America.

Although the concept of using technology to improve health care has existed for many decades, the time has come to establish a national health information infrastructure that will encourage the public and private sectors to invest in information technology while adequately safeguarding consumers. To be ultimately useful, systems must be carefully designed to produce care that is safe, effective, patient-centered, timely, efficient, and equitable.⁹

We already know that new technology that aids in administering medications can reduce medical errors and prevent death or unnecessary injuries. However, the technology and communications infrastructure in public and private mental health care lags far behind other sectors.⁹

The time has come to establish a national health information infrastructure that will encourage the public and private sectors to invest in information technology while adequately safeguarding consumers.

To address this technological need in the mental health care system, this goal envisions two critical technological components:

• A robust telehealth system to improve access to care, and

• An integrated health records system and a personal health information system for providers and patients.

Access to Care Is a Concern in Rural and Other Underserved Areas

Emerging technologies provide the means to overcome geographical distances that often hinder access to care. Health technology and telehealth now offer powerful tools to improve access to mental health care in rural, remote, and other underserved areas.

Emerging technologies provide the means to overcome geographical distances that often hinder access to care.

Telehealth - using electronic information and telecommunications technologies to provide long-distance clinical care and consultation, patient and professional health-related education, public health and health administration - is a greatly underused resource for mental health services. Tele-home care and consultations can increase access to mental health care for all patients, but especially for individuals with multiple chronic health conditions, those with severe illness and disability, underserved populations, children, and the frail elderly.

Information Technology Can Now Enhance Medical Records Systems

Information technology is now available to support integrating electronic health record systems. Integrated systems can promote high quality, coordinated services by helping psychiatrists and other physicians, psychologists, social workers, nurses, and other health and human service providers communicate vital health information clearly, confidentially, and when it is needed.

The Institute of Medicine, the National Committee on Vital and Health Statistics, and the National Quality Forum have all proposed widely implementing a paperless, interoperable communications and information technology infrastructure as a way to improve and integrate the Nation's health care system. Mental health can lead this change.

Already, the Federal government is working to establish guidelines and standards to more effectively transmit, communicate, and protect health information. For example, by agreeing to use the same health messaging standards, pharmaceutical codes, imaging standards, and laboratory test names, the country is one giant step closer to speaking a common language and providing better patient care - thus leading the way to a more integrated health care system.

Consumers May Not Have Access to Reliable Health Information

Science has produced large volumes of information about breakthroughs in health promotion, disease prevention, diagnosing and treating illnesses, and recovery. However, a reliable source for this information is not easily or universally available to all Americans.

Although the Commission found that most consumers and families want up-to-date information about the mental disorders, symptoms, treatments, and supportive services for the mental disorders with which they are dealing, such information is seldom available when people need it most. The Commission supports developing a personal health information system to that enables every American to obtain, maintain, and share personal health information.

Achieving the Goal

Recommendation

6.1 Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.

Underserved Populations Can Benefit from Health Technology

Telehealth and e-health technologies hold great promise for improving access to mental health care in many rural, remote, and other underserved areas. By using computers and video cameras, sending e-mail reminders, transmitting results by telephone, and assisting provider follow-up, underserved, rural, and remote communities could significantly improve care for individuals of all ages who have multiple chronic health conditions, including severe illness or disability.

However, a number of barriers must be removed to make these new technologies practical. The Commission recommends that States address the barriers created by restrictive licensure and scope-of-practice restrictions that impede developing technology-based services.

Public and private payers of health care costs do not yet appropriately cover or reimburse for e-health and telehealth services. Reimbursement must become flexible enough to allow evidence-based practices to be implemented, coordinating both traditional clinical care and e-health visits and ensuring that services delivered through new technology are sustained. Doing so will require changing policies and supports in all sectors of the health care industry.

The Commission encourages public and private payers to reimburse for e-health and telemedicine services. The Commission recommends that the U.S. Department of Health and Human Services (HHS) lead a review of how to best deliver and finance these services in consultation with private payers, insurers, State agencies, and other Federal programs.

Recommendation

6.2 Develop and implement integrated electronic health record and personal health information systems.

Electronic Medical Records Will Improve Coordination and Quality

With the explosion of scientific advances, new treatments, breakthroughs in promoting health, and medical information, all providers must have high-speed electronic access to the latest evidence-based practice guidelines, best practice models, ongoing clinical trials, scientific research, and other health information.

Studies show that electronic health records improve quality, accountability, and cost-effectiveness of health care services.^179-181 Enhancing communication between informed consumers and health care professionals improves their discussions about treatment options and more knowledgeable decisions. Health care providers, including those in the mental health field, urgently need universal access to real-time, computer-based health records. Successful models of person-centered, integrated, comprehensive electronic health records already exist, such as the Department of Veterans Affairs' (VA) health record system. (See Figure 6-1.)

Figure 6-1. Model Program: Veterans Administration Health Information and Communication Technology System
Program	U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA): Use of Health Information and Communication Technology.
Goal	Improve the quality, access, equity and efficiency of care by using a fully integrated electronic health record system, personal health information systems, and telemedicine.
Features	VHA is the largest integrated health care system in the U.S. with approximately 1,300 sites providing a full continuum of health care services. VA provided mental health services to more than 750,000 veterans in 2002. All VHA medical facilities (clinics, hospitals, and nursing homes) use a fully integrated electronic medical record that is capable of supporting a paperless health record system. The VA system incorporates clinical problem lists, clinic notes, hospital summaries, laboratory, images and reports from diagnostic tests and radiological procedures, pharmacy, computerized order entry, a bar-code medication administration system, clinical practice guidelines, reminders and alerts, and a specialized package of mental health tools. In addition, VA uses innovative information technology and communication systems to give beneficiaries information on benefits and services, allow web-based enrollment, support a national electronic provider credentialing system, provide veterans and their families access to health information and support health care provider education. Telemedicine is used to increase access to primary and specialty care for rural and underserved populations. VA provided approximately 350,000 telemedicine visits and consultations last year. Telemedicine mental health consultations and follow-up visits provide access to these services at locations where they would otherwise be unavailable.
Outcomes	In 2002, the Institute of Medicine reported, "VA's integrated health care information system, including its framework of performance measures, is considered to be one of the best in the nation."182 Utilizing an electronic health record with a clinical reminder system, VA screens 89% of primary care patients for depression and 81% for substance abuse. In VA, 80% of patients hospitalized for mental illnesses receive follow-up outpatient appointments within 30 days; the next best reported performance by NCQA is 73% and the Medicaid average is only 55%.
Biggest challenge	The public's lack of confidence in the privacy and security of the electronic health record and the lack of national standards for data and communications represent the biggest challenges to implementing such a system.
How other organizations can adopt	High-performance, reliable electronic health record and information systems are currently available for use by any provider, clinic, hospital, or health system. Incentives for adopting electronic health records would speed wider use.
Sites	All VHA clinics, hospitals, and nursing home facilities nationwide

An integrated, interoperable, electronic health information system - linked by an individual, privacy-protected key card - could enable a virtual health care team and a coordinated system of care to extend across place, providers, plans, and time. Exchanging health information through secure means - including appropriate authorizations from consumers - can connect information from health-related entities with consumers' personal health information. This connection will make important data available at the right times and places to support optimal care and recovery for consumers.

Electronic mental health records may enhance quality by promoting adoption and adherence to evidence-based practices by including:

• Clinical reminders;

• Clinical practice guidelines for prevention, treatment, and monitoring;

• Tools for decision support;

• Direct computer entry of health care instructions and prescription dosages; and

• Patient safety alert systems.

Another promising practice - using individualized, computer-generated reminders - will also become possible with electronic medical records.

Other innovations in mental health care are even more viable with the technology for electronic medical records. For example, using hospital bar-codes to administer medication reduces medication errors and, thus, improves patient safety.¹⁸³ Electronic medical records also provide a platform for consumers to receive computerized, clinical instructions and automated alerts for drug interactions, contraindications, and allergies.

The Commission recommends that HHS and VA lead a voluntary public-private initiative to design and adopt a secure, privacy-protected, electronic health record and a system of health information exchange for providers to share information with the approval of consumers. Privacy and security of this system must remain primary concerns. The Commission proposes this national health information infrastructure not as a centralized government database, but rather as a means to connect and exchange health information in the framework of a secure, decentralized network.

• The design initiative should involve Federal, State, and local governments; professional organizations; health care consumers; advocates; providers; payers; purchasers; and other relevant groups.

• The Individualized Plan of Care should be included in the electronic health record and be developed along with the proposed Comprehensive State Mental Health Plan. (See Goal 2 for a discussion.)

• The system should include state-of-the-art treatment guidelines and clinical reminders that promote using standardized evidence-based and promising practices in managing serious mental illnesses for adults and serious emotional disturbances for children. System administrators should incorporate these innovations into the electronic medical records systems providers use in clinics, offices, hospitals, and acute care and long-term care settings.

Personal Health Information Systems Can Help Consumers Manage Their Own Care

The Commission found that the general public can now access a great deal of valuable health information through the Internet. Most consumers and families want up-to-date information about the symptoms and mental disorders with which they are dealing, as well as information on effective treatments and supportive services. But today, reliable information is not always available when and how people need it most, and it is not readily or universally accessible to all Americans. Consumers should have the choice and capability to obtain, store, and share their personal health information.

Systems are already available to support access to Internet assessment services and health information sources in order to build a personalized health information library. Consumers can use these systems as research tools to:

• Evaluate the quality of care provided,

• Participate in on-line support groups,

• Evaluate best practices,

• Learn about the most recent treatment breakthroughs, and

• Determine how to best use resources they manage.

Consumers should have the choice and capability to obtain, store, and share their personal health information.

The Network of Care for Mental Health, an individualized mental health resource Web site, provides a model for how consumers can use Internet technology to find pertinent mental health information; identify available services, supports, and community resources; and keep personal records on secure computer servers. (See Figure 6-2.)

Figure 6-2. Model Program: Individualized Mental Health Resource Web Site
Program	Network of Care for Mental Health
Goal	To help ensure "No Wrong Door" exists for those who need mental health services.
Features	The user-friendly Web site enables consumers and families to find pertinent mental health information; identify available services, supports, and community resources; and keep personal records on secure servers. Consumers and families can search the site's comprehensive Service Directory - by age group, diagnosis, program or agency name, key word, or by using the 20-category menu-for mental health treatment and supportive services provided by the county and other organizations. The site also offers up-to-date information about diagnoses, insurance, and advocacy, as well as daily news from around the world concerning mental health.
Biggest challenge	Gathering and organizing an enormous amount of information while making it easily accessible to Network of Care for Mental Health Web site users represents the major challenge.
How other organizations can adopt	The Network of Care Web site can be easily and cost-effectively replicated in any location because the entire infrastructure - and many of the data components; e.g., the library and national links - are identical from one region to another. Only certain county-specific data (e.g., available mental health treatment and support services) must be developed for each new site.
Sites	The San Diego Network of Care for Mental Health Web site was launched April 30, 2003; another is now being developed for Los Angeles County, California.
Web site	http://www.networkofcare.org

Consumers and families must be assured that their privacy and the confidentiality of their health information are well protected. If health care systems do not make substantial, front-end, ongoing investments to protect privacy, electronic health information systems are doomed to fail. Existing Federal regulations that balance privacy protections and the need for shared information within the health system, such as the Health Insurance Portability and Accountability Act (HIPAA), must be constantly re-examined to ensure that they adequately address both provider and consumer needs.

If health care systems do not make substantial, front-end, ongoing investments to protect privacy, electronic health information systems are doomed to fail.

The Commission recommends that HHS and VA lead a public-private effort to create and promote use of software for Internet access to privacy-protected, personal health information that consumers maintain and control. Consumers and families must be involved in designing, evaluating, and implementing the system that would enable them to personalize their records. The software and training should enable consumers to personalize their health information record through links to key portions of their health records, local consumer support groups, self-care trackers, advance directives, and directories of local service providers located in or near their own ZIP Codes. This personal health information system should include the following elements:

• Electronic copies of key portions of individual health information, including records from health care providers, laboratories, and pharmacies; personal health trackers; and advance directives, care reminders, and self-entered health information;

• Access to Internet assessment services and health information sources so that they can build a personalized health information library;

• Interface with a wide range of services and programs, including prescription, appointment scheduling and reminders, medication refills, participation in consumer and support groups, and alerts to new research findings and projects;

• Availability to the general public, consumers, and families; and

• Universal design to ensure access for people with sensory perceptual and physical disabilities and availability in a broad range of multilingual formats.