Computer HIT in the 90s

Healthcare Informatics: Behavior's Problem

Behavior's Problem Overwhelmingly regulated by managed care, behavioral health providers still struggle for--and against--computerization

by Wendy J. Meyeroff and Richard E. Meyeroff March 1999 - Healthcare Informatics

Treating mental health problems is complicated enough without managed care issues, and with them, behavioral healthcare becomes a field in desperate need of IT solutions.

Experts point out that behavioral healthcare by its very nature is vulnerable to patients who abuse the system. After all, when an orthopedist checks a broken leg he or she can tell whether it has healed or not; it does the patient no good to insist that the leg's still broken. It's much easier for patients to manipulate ongoing care for depression, anxiety or other problems. For the same reason, it is also easier for practitioners to misdiagnose and treat mental health problems.

The opportunities for abusing the system, misdiagnosis and mistreatment, say the experts, are why behavioral health is one of the areas most regimented by managed care. According to Craig Muzilla, VP of marketing and business development for Instream, an electronic commerce company in Burlington, Mass., "Eighty-five percent of behavioral health is under some type of managed care. That's the highest percentage of any healthcare business."

Such regimentation doesn't come cheaply. A study conduced

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Healthcare Informatics: Behavior's Problem

firm in New York City, notes that managed care is 50 percent more costly to administer than fee-for-service. Cost cuts were achieved, says Tom Cayton, PhD, project director for The Psychological Corp. in San Antonio, Texas, distributor of traditional and electronic psychological tests, "by reducing access through establishing hurdles."

Those hurdles multiply horrifically in behavioral healthcare.

Whereas a broken leg really only dictates one course of treatment, the options are staggering when it comes to treating something like depression. Does this patient need medication, group therapy, biofeedback, a combination--or something else entirely?

Meeting individual needs The number of behaviors one has to evaluate, code, track, etc., is staggering. Jim McGrody, VP of marketing for The Psychological Corp. notes that the company's OPTAIO systems evaluate about 1,600 different behaviors and problems, derived from the American Psychiatric Association's DSM-IV list.

McGrody says equipment and software often are not the main obstacles to provider use. (The OPTAIO programs, for example, can run on Windows in a stand-alone format or networked via a wide area network.) Rather, The Psychological Corp. has found that the biggest obstacle to getting providers to use computerized systems is that too often those systems don't meet their demands. "The IT systems are designed by IT guys...and too often the resulting system doesn't meet clinical needs." The result is the infamous GIGO (Garbage In, Garbage Out) and providers who are asking, "Why should I learn your new computer system, or fill out some computerized form, if it's not going to help me help my patient?"

Heather Porter, director of marketing and community outreach at Elmcrest Behavioral Health Network in Portland, Conn., notes one of the ways they are avoiding this scenario.

"We've put together an MIS steering committee. It consists not just of MIS people, but also reps from accounting, case management, admissions, purchasing and other departments."

The IT challenge Consider the paperwork involved in behavioral healthcare.

Muzilla explains the nightmare: "You start, let's say, with a referral from the primary care doctor to the managed care

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organization, which is then routed to a specialist in behavioral healthcare. The new provider does an initial assessment and may apply for a precertification from the managed care organization to see the patient for one or two visits. After these visits, the provider rolls out a formal treatment plan to the managed care organization, which sends back treatment authorization for X number of visits. At the end of this cycle there's a closing summary." All of that adds up to a lot of forms flowing back and forth.

That's assuming the provider doesn't feel treatment should be extended. If he or she does, there's more paperwork, more reviews and more communication between provider and case managers. (Case managers are another expense specific to behavioral health; they tend to be licensed professionals such as psychologists.) "Good healthcare is 90 percent information exchange," according to Mark Gerner, CEO of WorkFlow Designs, a consulting and training firm in Dallas, specializing in Web-based applications.

It's already easy to see why computerizing behavioral healthcare gives IT managers nightmares, but Ken Hawes, executive VP/CIO of Magellan Behavioral Health, a specialty managed care organization, says that's the tip of the iceberg.

He points out that there is a whole different set of challenges from IT's perspective. Among them: companies shortening time frames for implementation of new systems or system changes; accommodating special customer needs (like generating special reports); accommodating changes like regulatory accreditation; handling confidentiality issues; juggling differences in benefit plans; and the general lack of standardization in healthcare.

Of course, claims and billing are undoubtedly major concerns with any new computer system. Magellan has not one, but two claims systems. The HMO work is handled by Hewlett-Packard hardware on an AMISYS platform, while the employer union uses an IBM-driven AS/400 system. The public sector uses either--depending on the complexity of the specific claim it's processing.

But it's important, say the experts, to think beyond claims to the total data the system can process. For example, one of the many benefits of Magellan's new clinical system is instant transfer of authorizations, so patients receive the care they need without unwarranted delays.

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Other concerns that can benefit from computerization: ● Maintaining efficiency--Experts point out that behavioral healthcare is being downsized in many organizations and computerization allows agencies to maintain standards even when personnel and budgets have been slashed. ● Enhancing patient care--Modules match patients with the "right" provider: For example, some patients may need someone who is female and speaks Russian. ● Analyzing and modifying treatment--Group Health has recently put in place a system that allows the assessment of populations individually, so as to look at the effectiveness of treatment over time. ● Saving money--Instream notes that electronic commerce can provide extensive savings to a managed care organization, in great part by cutting down on the personnel needed for data processing. In its model for Instream, Towers Perrin estimated that using e-commerce, the average managed care organization would realize a 140 percent increase in net income, plus an overall decrease in operating expenses. ● Saving time--Most programs have a feature that allows standard information like the provider's name, ID, etc., to insert automatically in the appropriate fields. That means the time the provider spends entering the same details from form to form can be used to either complete different details or shift back to clinical work.

The bottom line, say the experts, is that technology and behavioral healthcare must work together. According to Les Ruthven, PhD, president/CEO of Preferred Mental Health Management (PMHM), Wichita, Kan., a company that arranges and manages behavioral healthcare services for at least 50 national companies covering 600,000 lives: "Managed behavioral care cannot be done competently without the technology to handle it. We have to make use of technology. But it can't make up for experts in the field.

Clinical judgment is still very important."

Deciding where to start Marlan Crosier, MIS manager for Behavioral Health Systems of Group Health of Puget Sound, Seattle, says the technology "falls into place" once his organization decides what it wants to do.

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Crosier's advice might sound simplistic, but it's actually repeated in one form or another by other IT experts, whether they're working inside an operation or outside. "The first thing we ask every client is to define their problems," Gerner says.

For example, the Texas Commission on Alcohol and Drug Abuse came to WorkFlow Designs for a way to keep information moving smoothly from all sorts of behavioral health experts with various types of computers. The company recommended focusing on the lowest common denominator (for example, the field agent with a beat-up laptop instead of the caseworker with the best equipment in Dallas). The solution was a Web browser for what is now the Behavioral Healthcare Network.

Porter says one productive step they've taken is compiling a "wish list" of what they need from a behavioral healthcare system. Among those needs: a free flow of data among the network's 10 locations throughout Connecticut and an electronic medical record.

One of the most important aspects of Porter's wish list is the ability to track behavioral healthcare across various levels.

She explains, "Generally, managed care is concerned with tracking illnesses across one episode. A patient is admitted, then discharged. That's one episode." But in behavioral healthcare, a patient can move across several levels of care, from outpatient to day treatment to inpatient care, and it's all considered part of the same episode.

Crosier and his team also don't reinvent the wheel. "We've found the organization's general medical system works pretty well in behavioral healthcare," Crosier says. "We each use the same system for claims, billing, pharmacy, making appointments, tracking visits, etc." Group Health uses IBM or Tandem mainframes. The software includes Statistical Analysis Software and a number of Microsoft products (including Access and Excel). Crosier adds that they use Microsoft for at least two reasons: It's always easy to find people to work on these programs, and they feel the established company gives them a solid upgrade path.

Having information technologists around at the beginning is not enough, however. Experts agree that regular contact between IT and behavioral healthcare professionals is critical.

Crosier says it's important that he's actually part of Group Health's Behavioral Health division "and not off in another

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tower somewhere." He understands the real problems of the healthcare professionals, and that they're not computer experts. This understanding helps him find technological solutions that are as painless as possible for the behavioral healthcare workers.

Michelle Hertel is MIS director of PMHM. She believes that working her way up through different departments has not only allowed her to truly understand--and better solve--each division's problems, but to do so in a way that integrates each department's individual solution into PMHM's system as a whole. To further enhance communication between Hertel and the rest of the organization, directors meet at least every two weeks.

Saving face time At Magellan, this kind of interface can perhaps best be seen by work that was needed to allow the convergence of three clinical systems that were handling about 90 percent of the business. Magellan handles behavioral healthcare for three types of business: HMOs, employer unions and the public sector (Medicaid). Hawes says IT planning, begun two years ago (even before the three companies from which Magellan sprang, merged) was to develop the clinical system for the HMO business, which is the least complicated. But how do you keep that plan fresh, given the changes in both behavioral healthcare and technology?

The answers: For two years, information and ideas have flowed back and forth. Additionally, a model office--designed to actually test revised concepts and new technology--was built in Columbia, Md. Last spring, the work culminated with about 22 reps from across the company--including various behavioral health experts--spending two weeks on-site at the office to do a complete functionality review before signing off and saying "Yes, we can use this."

Maintaining confidentiality Confidentiality is a major issue when computerizing behavioral health records. The Web site for the American College of Physicians contains dozens of articles in its journal in which doctors talk about what (if any) information can be safely entered into a patient's chart--and the various computer options to choose from.

Courtney Ruthven, PhD, executive VP of PMHM, notes that having licensed psychologists act as case managers is one step

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toward solving confidentiality issues. After all, she says, if a managed care organization case manager contacts a provider to receive more extensive details on a patient's condition and further treatment is deemed necessary, the information is being exchanged between two professionals bound by confidentiality agreements.

Still, privacy remains a key concern in behavioral healthcare.

Muzilla notes that Instream runs on Windows 3.1 or 95. He believes it could run on a Mac with emulation software running OS 7 or later. The software provides a private network, based on TCP/IP. All data is encrypted in a 128-bit data encryption private key, using the messaging protocol SMIME. Even with such assurances, many organizations opt to keep all computerized records on-site. PMHM has about 30 Pentium 200s (plus some 100s for basic clerical work), running a custom database using Paradox 3.5 for DOS with both a Novell and NT server. The intention is to move to Visual Foxpro with Windows. "Our patient records are not accessible to anyone outside the network," Courtney Ruthven says.

Further, no clinical information is available to unauthorized personnel. "The claims people would see a diagnosis, like depression, but they wouldn't get any clinical details, such as why this person is depressed."

Wendy J. Meyeroff is a healthcare and computer writer and Richard E. Meyeroff is president of Meyeroff Computer Consultants in Brooklyn, N.Y. RETURN TO MARCH 1999 TABLE OF CONTENTS HOME | MAGAZINE | RESOURCE GUIDE | CLASSIFIEDS | SPOTLIGHTS | ADVERTISER SERVICES | CONFERENCES | EXHIBIT HALLS | REGISTER

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