The Battle Royal: Electronic Health Records versus Health Services Integration versus 42 CFR versus Big Data

Background Story of Kitsap Mental Health Services Electronic Health Records:  Electronic Health Records (EHR) have made a significant difference at Kitsap Mental Health Services (KMHS), a community behavioral health center serving Kitsap County, WA.   More than a decade ago, KMHS adopted an interesting invention called an “electronic health record system” as a means of documenting, sharing and improving quality services among our clinical teams.  After many years of use, we upgraded to another EHR platform as the demand, mandates and expectations for EHRs grew exponentially.  That change-over occurred on April 1, 2009 (no fooling).  Since then, KMHS has manipulated, adopted and twisted its current EHR system to keep abreast of the continued stream of demands, mandates and expectations.  

In 2012, KMHS received a Center for Medicaid and Medicare Innovations (CMMI) Award to develop a bi-directional model of integration for mental health, substance abuse disorders and physical care.  A huge part of that award involved the EHR and the use of Health Analysists and Medical Assistants to provide the data bridge between primary care providers and the mental health professionals and substance abuse disorder centers.  In our pioneering efforts to develop this bi-directional model of integration, KMHS became the first community behavior health center to contract with the Emergency Department Information Exchange (EDIE) system which provided us with documentation for every time a KMHS client used the emergency room, anywhere in the state.  This hook-up to our EHR proved challenging as it was like drinking from a firehose but doable and we initially began with faxes on ER use sent to us nightly.  This transaction evolved to where our EHR system now self-populates in real time with all EDIE data.  In addition to EDIE, KMHS has hooked-up our EHR to many other data sources, including the local community hospital, the State PRISM data system, the state prescription monitoring program, EPIC, and are currently hooking-up with the State’s new Health Information Exchange (HIE) in collaboration with our local Federally Qualified Health Center. 

Quality Benefits of EHR:  Because of the use of EHRs, we have seen a multitude of quality improvements that have been generated on behalf of those who we serve and with those who we collaborate with to provide comprehensive services across our communities.  A significant outcome has been the integration of physical care records into our EHR.  In many respects this integration has proven to be lifesaving.  Historically we would receive notice of an individual being diagnosed at Stage Four cancer because we had no communication with primary care.  This message was typically followed several months later with a notice of death of the individual.  Now with a direct communication, in real time, with primary care providers, when a client complains of a lump on their tongue, we let the Primary Care Provider (PCP) know immediately and monitor through our EHR.  The last two cancer cases were identified at Stage One!  The EHR has also let us know when an individual has used the ER the night before which then allows us to follow up on the situation, review the ER visit with the client and even assist with follow up appointments if scheduled.  Thus we work collaboratively with the health care system on behalf of those using our services.  Another benefit is the access to the State’s PRISM records which informs our treatment teams of encounters such as other mental health and health services that were utilized by an individual so we do not need to always replicate evaluations, send out for tests or essentially ‘rediscover the wheel’.  This means treatment can move progressively forward rather cycling backwards with duplication.  EHRs have also helped save lives by informing our treatment plans of allergies that were not disclosed, drug reactions from other provider’s notes or internal ‘bookmarks’ to keep a whole team up to speed on one individual’s care.  In addition, our EHR is hooked-up with the state prescription monitoring program which is the State’s program to improve patient care and stop prescription drug misuse by collecting all the records for Schedule II, III, IV and V drugs. This information is then made available to medical providers and pharmacists as a tool in patient care.  Now KMHS can access and integrate that information into our treatment planning as well.  Again, lives are saved as potentially harmful or addictive medications are now monitored across the state.  Finally, EHRs have provided a collaborative platform for our agency to work with primary care and other specialists on chronic diseases such as diabetes, hypertension, obesity, or high cholesterol.  Through the EHR we can communicate current levels and take appropriate action, provide access to relevant groups and do 1:1 education.  Even our treatment plan prints out highlights in ‘red’ if any of the chronic diseases are out of the normal range.  Such quick and regular monitoring leads to an overall better quality of life and often times a longer life.

Challenges of the EHR:  The EHR systems are not the ‘be all, end all’ by any means.  There are many significant challenges that we have faced and currently face despite our successes noted above.  One initial concern is that when the mandate was made to move to EHRs, there were no established guidelines, guard rails or common criteria to guide the development of EHRs. Unfortunately the lack of consistent guidelines for development and the tsunami of EHR companies competing for the market created a huge issue of EHR interoperability.  However, gradually time and demand is pushing EHRs to develop some common languages and platform structures so we can literally cross-talk but it is NOT as easy as it should/could be.  A second concern is the volume of information that EHR’s are able to transmit greatly exceeds the capacity of a small or even mid-sized agency.  Essentially we become faced with the problem of ‘big data.’   Big data is defined by the volume of data we receive, often times transaction data that has been stored for years is suddenly released.  Then there is the velocity of the data which is streaming in at unprecedented speed and must be dealt with in a timely manner. Furthermore data comes in a vast variety of formats and the complexity of today’s data comes from multiple sources making it a significant undertaking to link, match, cleanse and transform data across systems. Thus we have pushed for the ability to receive data in real time AND have it self-populate in our EHR.  However, with those demands met, we often have to set thresholds on when the data can become actionable because the amount is overwhelming.  This leads to the third concern which is ability to translate data into information which only then can it be use by the treatment team in a viable manner.  We were fortunate to be able to hire Health Analysists from the CMMI award who become self-taught experts at manipulating the volumes of data into pivot tables in order allow clinical teams to extract critical information for treatment plans.  A forth concern is simply the lack of fiber optics network throughout the state.  KMHS was just able to access fiber in the last few years.  Many of my rural and suburban (and yes, even some urban) colleagues lack access to fiber which then renders the best EHR to a big fancy screen saver.  The problems of big data mentioned earlier become severely pronounced when the EHR has to transmit through DSL or other restrictive means.  Imagine funneling that firehose through a drinking straw.  Even the finest, greatest EHR can't overcome a restricted infrastructure.  Finally, and perhaps most importantly, is that our EHRs and integration efforts are severely undermined by the Code of Federal Regulations Title 42 (otherwise known as 42 CFR).  This essentially prevents the transmission of any information and/or data that may contain any information or reference to alcohol and/or drug use without the consent of the individual and the identification of the receiving entity’s name as well as the receiving individual’s name.  Thus all of the treatment plans that are integrated with mental health and substance abuse disorders have to be fully redacted before transmission across a HIE unless the agency has obtained all the proper releases, signatures and assurances that such information will go to ONLY the entity and individual so named which is next to impossible to assure via EHR, especially if your service delivery system is build on treatment teams.  Thus as agencies we have been mandated to ‘integrated’ yet we are penalized if we transmit any of the integrated information without the archaic protocols that are unreasonable to secure and transmit.  This often results in agencies redacting the 42 CFR information.  The other physical and mental health information is not held to such a high level of restriction.  However, as an agency that provides integrated services, it pains me to restrict information that may best inform a provider when treating an individual.  

In closing, our advances in the quality of life and literally ‘life saving’ capacity of EHRs has been demonstrated and it is critically important to integrative services which will achieve better services, provided more efficiently and at a lower cost.  However, we need to address the challenges of big data, interoperability, exchanges, and most significantly the 42 CFR implications, as those were rules made long before an EHR was even conceptualized.