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Readying for the RHIO revolution: a look at what's ahead for behavioral healthcare providers.

They might sound futuristic, but the fact is that regional health information organizations (RHIOs) are already here in some communities. So the question for the behavioral healthcare field is no longer whether community-wide databases and communications systems will exist in healthcare, but rather how they will affect mental health and substance abuse professionals' service delivery.

The subject of much anticipation, some excitement and, for many, considerable concern, RHIOs have the potential to transform how behavioral healthcare professionals interact with primary care and acute care professionals, along with healthcare organizations. Industry experts say there definitely is the potential for greater continuity of care and better overall communications, but privacy, security, cost, and care coordination concerns remain important hurdles.

RHIOs in Brief

A RHIO is a nongovernmental organization that oversees interoperable electronic health information, allowing for the sharing of data among physicians, hospitals, local public health agencies, and other entities. At press time, only a handful of RHIOs actually are sharing data, but dozens are in the final planning or early implementation stages. The federal government, through the Office of the National Coordinator for Health Information Technology, envisions RHIOs as the building blocks for the goal, articulated by Congress and the Bush administration, of building the National Health Information Network, a nationwide data-sharing structure that could act as an overall umbrella for all RHIOs nationwide. While all healthcare leaders trying to create and develop RHIOs share certain broad goals, such as improving patient care and creating greater clinician efficiency, the specifics of individual RHIO initiatives vary greatly. In other words, if you've seen one RHIO, you've seen one RHIO.

Among the many challenges ahead are creating efficient operational mechanics for each data-sharing organization, developing effective governance structures, garnering broad participation from a variety of providers and patient care organizations in a community or region, funding the operation of each RHIO, and handling security and privacy concerns. Considerations specific to behavioral healthcare professionals include concerns regarding patient privacy, interactions with other healthcare professionals, technology development and financing, and interconnectivity.

An Early Success

Behavioral healthcare professionals and industry leaders with understandable concerns about some of the challenges involved in RHIO development might want to check out what's happening in Mesa County, Colorado. In Grand Junction, the county seat, a coalition of the three main hospital organizations, the main physician organization, and the area's largest insurer has been organized to build a RHIO from the ground up. Although the RHIO is still quite new--it went live in late October--the information organization has been designed with scrupulous concern for the needs of behavioral healthcare professionals, primary care physicians, specialists, and patients alike, says Dick Thompson, executive director of the RHIO (named Quality Health Network). For example, after meeting with representatives of all the health disciplines involved, their interests, considerations, and concerns were built into the process at Quality Health Network.

"We founded this RHIO with the vision that everybody needed to 'play,' because our goal is to exchange information in order to optimize the health of the community, and everything is driven by that," Thompson emphasizes. In fact, one of the first healthcare professionals to be plugged into the network was John Halvorson, PhD, a clinical psychologist who is the coordinator of the Behavioral Sciences Program and Residency within the St. Mary's Family Practice Residency, which is the training organization at St. Mary's Healthcare in Grand Junction.

The RHIO's implementation facilitates Dr. Halvorson's communications with physicians, residents, and staffers at St. Mary's Family Practice Residency. While his laboratory, pathology, and other orders are delivered directly to his database, as clinically appropriate, Dr. Halvorson can direct encounter notes, transcriptions, and other materials electronically to the appropriate physicians he needs to communicate with at St. Mary's. From the other direction, he can receive electronic referral information from any physician in his RHIO-certified electronic address book.

Dr. Halvorson says he has been very pleased with how things have gone so far. "The few problems have been very minor," he adds, "and Dick Thompson and his crew have provided excellent training and support." Dr. Halvorson says he might be a good test case for the performance of RHIOs, being a classic mental health professional who has long been extremely careful to guard the privacy, security, and confidentiality of patients' records.

According to Thompson, thoughtful, purposeful collaboration among disciplines is key to building a successful RHIO that includes behavioral healthcare. "I truly believe a collaborative approach enhances the potential for improving outcomes," he says. "That's very clear. The challenge is to coordinate that care so that the behavioral health professional and the patient are satisfied that the confidentiality and privacy of that special relationship are maintained." Quality Health Network hasn't had any specific problems incorporating behavioral healthcare data into the RHIO thus far, but it's still very early in the process, Thompson concedes.

Many Concerns

While Quality Health Network appears to be a good example of a RHIO that has been thoughtfully developed, with strong consideration for the concerns of behavioral healthcare professionals, industry experts and practicing mental health professionals certainly have a broad range of concerns with regard to RHIOs' overall development. Indeed, RHIO development "is probably on the top of the top-three list of issues" for members of the National Council for Community Behavioral Healthcare (NCCBH), according to NCCBH President and CEO Linda Rosenberg. "We have a member listserv, and this has generated the most interest," she notes.

On the one hand, Rosenberg says, NCCBH members understand that connecting to electronic health record (EHR) and messaging capabilities will help mental health professionals increase "productivity, transparency, and quality." On the other hand, participating in RHIOs will require a double leap for the vast majority of behavioral healthcare professionals, very few of whom are currently linked to EHR systems now, and most of whom are still practicing with little computer-based automation.

Among the key concerns Rosenberg hears from members regarding RHIOs are worries about patient information privacy and security, concerns about usability and user-friendliness, interest and involvement in the governance structure, and concerns over financial considerations and practical connectivity issues.

One helpful development of late, Rosenberg notes, is the release in November of the Institute of Medicine's (IOM) report Improving the Quality of Health Care for Mental and Substance-Use Conditions. "There are recommendations related to the national health infrastructure, and there's encouragement for EHR development for mental health," she notes. "That's very powerful and, of course, our members are very aware that that's where things are going. Some of our members are already up to their second or third iteration of a clinical health record, while others are just thinking about it."

The IOM's recommendations will be powerful in helping to shed light on some of the steps that will be required to safely and effectively bring mental health into the RHIO world, agrees Ronald Manderscheid, PhD, who at the time of this writing was chief of the Survey and Analysis Branch at SAMHSA's Center for Mental Health Services. Still, says Dr. Manderscheid, "It will be incumbent on us [in the behavioral healthcare field] to educate the primary care and acute care people. We need to be reaching out to the primary care field and helping that field understand what behavioral healthcare is all about, and the technology and information differences. We need to achieve better coordination, in general, between primary care, behavioral, and substance abuse care, which is the substance of the IOM report's recommendations. A subset of that is that we need to achieve better coordination on information technology, as well."

Getting down to a more granular level in terms of availability of useful data will be a challenge, Dr. Manderscheid says. "There will be primary care-driven RHIOs. And the issue for us will be, what are the data standards in those RHIOs regarding behavioral healthcare information/data in those primary care offices? How will we resolve the problem of interoperability between behavioral health records, the primary care records, and the RHIOs?" Dr. Manderscheid says SAMHSA definitely will be involved in helping to develop data standards.

Among other current initiatives, SAMHSA is developing a behavioral health standards component for a nationally standardized EHR format to be presented to HL7, the healthcare industry's information technology standards organization. SAMHSA is actively studying the RHIOs emerging nationwide to help inform behavioral healthcare professionals as to what shape RHIOs will be taking. He also notes that the Software and Technology Vendors' Association (SATVA), a trade group of behavioral healthcare software vendors, is actively involved in interfacing with other organizations in this sphere.

Potential for Integration

Those behavioral healthcare professionals involved in the process of creating data interchanges agree that a potent mix of potential pitfalls and opportunities exist, but there is no question, they say, that behavioral health professionals need to be involved. "The first question is, where do the data reside? And then, who owns the data?" asks Dennis Morrison, PhD, CEO of the Center for Behavioral Health, a 285-FTE behavioral healthcare practice with 200 clinical professionals in Bloomington, Indiana.

Dr. Morrison notes that a large med-surg hospital is trying to build a RHIO in his area, while the Center for Behavioral Health has received a grant to promote data sharing between primary care and behavioral healthcare. "We're not calling it a RHIO, but that essentially is what it is," he explains. As the situation in Bloomington illustrates, RHIO development could be a complicated process, with differing and/or competing integration initiatives emerging in local communities that, at some point, probably will need to be reconciled.

Dr. Morrison's organization is certainly on the leading edge and a good candidate for RHIO development from the behavioral health side: The Center for Behavioral Health has had paperless operations since July 2003, and it has implemented several core electronic applications. Of RHIOs, he says, "They have the potential of being very helpful, from the standpoint that in many ways, our future in behavioral healthcare is intimately linked with primary care. If you have a working relationship with a primary care physician, you really can do integrated care, which has been one of the holy grails in our field."

In the end, RHIOs and interconnectivity with primary healthcare appears inevitable and, given the right kinds of safeguards and considerations for behavioral healthcare, desired. "People should be receptive and participative," advises St. Mary's Dr. Halvorson. "I went through some earlier resistance myself, regarding a different type of change having to do with integrative care between mental health and primary care. I was tending to drag my feet until I understood it all. Once I adjusted, and got involved in the planning effort, it became much more appealing."

Mark Hagland is a freelance writer who writes regularly on healthcare information technology topics. To send comments to the author and editors, e-mail
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Author:Hagland, Mark
Publication:Behavioral Healthcare
Geographic Code:1USA
Date:Mar 1, 2006
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