On September 22, 2011, I attended a webinar sponsored by the Business Operations for Behavioral Health Collaborative, a SAMHSA-funded joint venture of the National Council for Community Behavioral Healthcare, the National Association of Community Health Centers, NIATx, and the State Associations of Addictions Services (SAAS). The topic of the webinar was Health Information Exchange and Behavioral Health.
This is an area that has interested and concerned me for quite a while. As developers of software for behavioral health providers, SOS has for years been monitoring developments in the arena of Health Information Exchange (HIE). This is the method by which Electronic Medical Record (EMR) software will exchange information among providers and healthcare organizations. The HIE is both the process of exchanging information and any repository of that information for easy access by those with rights to the data.
This is the bugaboo that has always bothered me as well as my colleagues in the behavioral health software trade association to which we belong (Software and Technology Vendors Association). SATVA members are committed to assuring that our products share information only as the law allows and as consumers wish.
Work is currently in progress to assure that a universal method of acquiring patient permission for release of their information is part of any HIE. Such a method would undoubtedly allow a patient to specify providers to whom their treatment and diagnosis information can be released and any providers to whom it cannot be released. But what happens when a patient changes their mind?
Here’s a hypothetical example that jumps into the future by a few years, when all or most healthcare providers have EMRs and are connected into their regional HIEs.
John D. is admitted to the Emergency Room of a local hospital after a panic attack that he interprets as a heart attack. Among the papers that he signs is a release for the ER to access any information in the regional HIE about his health conditions. Since he is not thinking very clearly as he is sure he is dying from a heart attack, he signs everything put in front of him. After he is medicated, stabilized and sent home, he wonders about what he signed and which of his health information will now be available to whom. Does he really want his optometrist to know that he was treated with an anti-anxiety medication and prescribed an antidepressant (which he decided not to take)? Is it necessary for his urologist to have this information? What does he do to protect just that ER visit information and keep it from being sent on to other providers?
And what do our mental health and substance abuse patients do to secure their sensitive information?
This process concerns me because of my experience that once a piece of information has been entered into some large electronic database, getting it out may be near to impossible. Several years ago, I attended a conference in New Jersey. I rented a car, drove to the city in which the conference was held, returned the car and paid my bill in a timely fashion, and returned home.
The next time I needed to rent a car was three months after Katrina flooded New Orleans when my mother and I returned to check on her home and attend the funeral of one of my uncles. For some reason, the car was reserved in my mother’s name…the airline tickets were purchased with her card…even though I had placed my name on everything. The rental agency manager noticed something wrong when we picked up the car; there was a block on my account even though there was no balance. She overrode the block, gave me the keys to the car, and we were on our way. I did not give it another thought.
In several return visits to New Orleans, I again rented cars from the same company and always wound up with a car, not even knowing there continued to be a block on my account. Each time the agent or manager overrode the hold and gave me the keys. In November 2010, we arrived in New Orleans on a Sunday. The agent and assistant manager decided they did not have the authority to override the block on my account and there was no one they could contact to clear it. They refused to rent a car to me and offered no solution. They gave me a phone number I could call on Monday, but did not even offer my 90 year old mother and me transportation to another agency. I cursed and swore I would never rent from their unprofessional agency again and called my brother to come pick us up. Fortunately, he was thinking clearly enough to suggest that we go across the highway to a different company and rent a car there.
I did call the company the next day and eventually got the written apology and clearance of my account that I requested. It took six years for this correction of an error to happen.
What processes will we insist be put in place to assure that patients can change their minds about release of information or correct errors or enter corrected information into their records? What kind of advocacy will be required? What do mental health and substance abuse providers need to do to assure that the privacy of their patients’ sensitive information will be handled as they choose?
Please share your thoughts about HIE and EMRs and where we are going with this process.
Are you a Jeopardy fan? If you are, I am sure you know that in January of 2011, IBM’s supercomputer, Watson beat two of Jeopardy’s all time money winners, Brad Rutter and Ken Jennings. Watson is an Artificial Intelligence that can understand questions posed to it in natural ‘human’ language.
WellPoint, a BlueCross collaboration, is the largest provider of health benefits in the country. Their plan is to utilize Watson to sift through their patient databases to make diagnosis and treatment recommendations to WellPoint physicians.
This idea is not at all far-fetched and certainly a reasonable way for IBM to make some money off their huge research and development investment in Watson. They have also purchased some other companies that position them well for movement into the medical sphere.
Over the last four years, IBM has spent more than $7.8 billion to acquire database analytics specialists Cognos and SPSS, both formerly public, as well as data warehouse company Netezza, along with other private companies. In the first half of 2011, IBM spending on research and development exceeded $3.15 billion.
—International Business Times, 9/19/2011
What WellPoint is proposing to do is a starting point for a task all EMR’s will ultimately need access to and participation in. In order to meet the requirements for ARRA stimulus funds, eligible providers will need to utilize their EMR’s to help them make clinical decisions.
Clinical Decision Support (CDS) is a process whereby the physician gets notices and alerts from their software to assist them in making clinical choices that are based on data and evidence rather than memory and intuition. The Centers for Disease Control and Prevention (CDC) hopes to see public health organizations utilizing population data and statistics to guide their choices. They believe this will be one of the most impactful effects EMRs can offer the public health. The Office of the National Coordinator for Healthcare IT (ONC) wants to see individual physicians using Clinical Decision Support to advise their patients. Clearly, WellPoint plans for this level of intervention: physicians will have access to the data Watson can provide to assist them in making diagnoses and recommending treatments.
We talked in this blog about some of the potential benefits of CDS back in 2009. Since then, research on the benefits of supported clinical decision making has continued. A Google Scholar search of ’decision support emr’ results in 16,800 hits. There have also been noted some shortcomings, most notably a phenomenon called ‘alert fatigue‘, wherein a provider gets so many alerts and notices that they stop attending to them or turn them off altogether. Obviously, we have lots to learn about how to present information to healthcare providers so they can use it most effectively for the benefit of their patients. WellPoint has decided to dive right in!
What do you think about being diagnosed by a computer? Will it be more effective or less so? What is the relevance of CDS for behavioral health?
Please share your thoughts below.
Last week I asked you if you were using a Personal Health Record (PHR). I got only one response…from a college friend who is a technical writer. John is involved with a PHR company called medkaz. This company believes that all electronic medical records should be driven by and owned by the patient. Accordingly, they have developed a thumb-drive based product that the consumer will carry around with them. It is fully encrypted, so the privacy of the patient is guaranteed.
I believe the idea is that the patient will bring their personal record with them when they visit a doctor. The doctor can download relevant information of the patient’s choosing into their own electronic medical record (EMR) system. At the end of the visit with the patient, they will upload their note onto the patient’s thumb drive. The doctor can subscribe to this system themselves, but even if they do not, they will be able to use the patient’s information. This is one way to make sure that the people treating you have the most current medical information about you.
Over the course of the last few weeks, the reason for concern about what information health systems have and how they manage it again came into the public light. The Stanford Hospital in Palo Alto, CA reported that 20,000 records of emergency room patients had been revealed online by their collection agency…one of their Business Associates. The information had been posted on a web site for just short of one year. One of the affected patients saw the posting of the information and reported it to Stanford Hospital and Clinics.
According to IDExperts, there is good reason for concern about the security of medical data. The street value for a stolen medical identity is $50. Using that information, a Medicare or Medicaid or other insurance fraudster can file claims for services never provided….and often get paid.
In other news this week, the White House has proclaimed September 11-16, 2011 to be National Health Information Technology Week. The purpose of the proclamation is to call attention to and educate the citizenry of the benefits of and need for Health IT that will protect the privacy of the patient and involve patients in their health care.
Finally, the Office of the National Coordinator for Health Information Technology (ONC) has announced their new website, HealthIT.gov, designed to become the leading national resource on health IT for both consumers and health care professionals. The goal of the site appears to be to encourage personal responsibility for one’s health and health care through wise use of technology and coordinated efforts with one’s providers.
It was a busy week! Is there news you would like to share?
In August, the National Coordinator for Health IT, Dr. Farzad Mostashari, spoke about the need for a ‘targeted strategy’ to involve consumers in eHealth. He is concerned that all of the efforts being expended to acquire EMRs and for eligible providers (EPs) to achieve meaningful use of those EMRs must become more patient-centered.
One provision of the meaningful use requirements that will become increasingly important is the need to be able to provide an electronic version of the medical note to the patient. While there are a variety of ways by which this can be accomplished, Personal Health Records (PHRs) and Patient Portals into the provider’s EMR are two.
My own insurer provides a PHR on their website. I can enter lots of personal information about myself and my health if I choose to do so. Superficially, it appears this information can be accessed only by me, but I do not believe this is the case. The insurer can likely access the information too. Since it is mostly info they can get from my claims (and the claims history is available on the page), I am not too concerned about it, but I have been somewhat careful about entering things. If I were not pretty healthy, I think I would enter nothing.
The PHR to which I have access is a proprietary one. In August, Google removed their hat from the ring by discontinuing Google Health as a service effective January 1, 2012. Microsoft is well-entrenched in the healthcare arena, so I believe they will keep their product, Microsoft HealthVault, around. I wonder of what use these will be until providers can send information to the PHR for the patient.
For the last few weeks, I have been working with our web designer on re-writing our website. Now that so many people access the internet from their smart phones, we want to be sure the site works well on mobile phones and tablets. This focus has me wondering about a few things. I hope you can clear up some of these for me.
- How many of you use a PHR?
- Do you feel secure storing your personal medical information online?
- Do you use a smart phone for email?
- If so, for what other purposes do you use the smart phone?
I am hoping I will get some comments and responses from you. I wonder how many of you feel comfortable with the speed with which our lives are moving into ‘the cloud’.
Please jump in now. This inquiring mind really wants to know!
I have been struggling with a topic for this week’s blog. The only thing that has come across my path that feels compelling is the hummingbird who showed up at our coral honeysuckle on Sunday. Unfortunately, integrating that ruby throat into my article does not seem like an easy task.
Sometimes, I feel like I have run out of ideas. When that happens, I am reminded of feelings I experienced as a child and young adult. I knew I was not an artist and felt myself also to be not creative.
It took many years before I learned that my creativity takes forms different than that of artistic individuals. At some point in the process of doing psychotherapy with some very difficult clients, I realized that most of my creativity takes the form of what I will call creative alternativism. Generating possibilities…especially possibilities for different types of behavior and different kinds of thinking…was the primary manifestation of that creativity. Helping my clients find different ways to be in the world in order to overcome their pain and problems was the most important way I expressed that creative urge.
I have since realized that I often apply that process to myself as well. Since I can be a pretty rigid person when it comes to my own thinking and behavior, I have found that I need to make systematic efforts to implement the alternatives I generate for myself. I may well come up with many ideas about how to change my behavior, but I need structure to implement those changes.
Three years ago, I knew that adding yoga into my fitness efforts would benefit my arthritic joints and relieve some of my stress. Signing up for a yoga class was the structure that allowed me to make that a regular part of my activities. After three years, I have found other structures to help me extend that one class to two and now into a daily practice. I need and use structure to implement the possible changes I creatively generate for myself.
I had an email this week from a colleague I have not seen in years. I was delighted to learn that for the past year, she has been painting! At age 60, she took a pastels class at her local community college. She was hooked on the medium and has found a new outlet for her creativity. In my experience, she has always been creative. She has been a psychologist and psychotherapist for her entire professional life. She has researched and written and published…an aspect of her professional creativity; and now, she paints!
I am delighted to know that a new aspect of creative expression can manifest itself at any age, as long as we are open to it.
How do you express your creativity? Do you manage to do this within your professional life? Does the place you work benefit from your creative endeavors, or is it just for you?
Please share your thoughts about creativity, regenerating it, and keeping our lives…and blog topics…fresh.
I am sure many of you remember the reports dating back to 2005 that celebrity patient files were being viewed by casual lookers…employees who had access to the University of California at Los Angeles (UCLA) Health System electronic medical record (EMR) but who had no legitimate reason to view those records. Well, the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has entered into an agreement with UCLAHS to settle potential HIPAA violations for $865,500. Additionally, UCLA has made a commitment to correct gaps in their security, to improve their policies and procedures to better safeguard patient information, and to adequately educate their employees.
In a separate case, FierceHealthPayer reported that WellPoint will pay $100,000 to the state of Indiana because they waited several months before notifying Indiana officials of a security breach that could have exposed the data of 32,000 members.
For me, the important issues here are the following:
- OCR is serious about data breaches and safeguarding patient protected health information (PHI).
- State laws are just as important as Federal law. You must know and follow those local regulations as well as HIPAA and HITECH.
- The cost of a data breach is significant and would put many small provider organizations out of business.
Have you reviewed your security and privacy practices and policies this year? Are you confident that your PHI practices are solid and that your employees are using the procedures as written? How do you review these and how do you educate your employees?
Please share your experiences and concerns about data privacy and security with us below.
This morning I read an editorial (An ounce of prevention could heal a pound of pain) by Dina Overland of the FierceHealthPayer newsletter. She decided to use her platform as the editor of a newsletter that is aimed at insurance payers to directly address those payers about prevention of healthcare problems and diminishing future costs. She focused on an area that behavioral health and substance abuse professionals work in often . . . pain.
Ms. Overland’s review of the Institute of Medicine’s (IOM) report on pain and prevention cited some facts I had not heard.
If that’s not jarring enough, here are some more staggering facts: The United States spends $2 trillion on healthcare, but only 4 cents of every dollar goes to prevention and public health, despite being among the best tools to reduce spending. For every $1 invested in prevention, we save $6 in projected healthcare costs, says Sen. Tom Harkin (D-Iowa), who participated in the Department of Health and Human Services (HHS)’s announcement
of its guidelines to incorporating prevention throughout the healthcare industry.
***
I could not help but think about the number of people who would never have become substance abusers if their chronic pain had been addressed and treated at an early stage. How many behavioral health clients have you treated for depression after years of experiencing intractable pain?
The IOM and HHS see the coordination of care among primary care providers and specialists as the best way to address early intervention and prevention of pain. What role should mental health and substance abuse providers play in this coordination? How many of your patients also experience chronic pain? Where do behavioral health providers fit in?
Please share your thoughts and comments below. What role do you want to play in diminishing healthcare costs? Who should we see when it hurts?
According to a June 14, 2011 report by Government Health IT News, consumers’ confidence in the safety of their data in electronic health records (EHRs) is a prerequisite to the successful adoption of electronic means of recording and sharing health records. So says Dixie Baker, chair of advisory Health IT Standards Committee’s privacy and security workgroup and senior vice president and chief technology officer for health solutions for SAIC. Feeling assured that their information is safe and secure and going only where it is supposed to go will allow the public to support their health care providers in moving to electronic medical records (EMRs).
In fact, Government Health IT News reported on June 24 that the Office of the National Coordinator for Health IT (ONC) plans to contract with a vendor “to explore and evaluate methods to electronically obtain and record from patients their informed consent about sharing their health data.” The solicitation focuses heavily on the matter of educating patients about disclosure and consent for release of information.
In substance abuse and behavioral health settings, requirements beyond those encoded by HIPAA and HITECH are mandated in federal and state laws. 42 CFR Part 2 applies to any provider or provider organization holding itself out as a provider of alcohol or drug abuse treatment and to federally assisted alcohol or drug abuse programs. Special “handling” of the record is required, especially when it comes to re-release of the information obtained. It is not acceptable for a provider to receive information from an alcohol abuse program, incorporate it into their EMR and then release it on to other providers of the patient, without the specific consent of the patient.
The legal complexities are immense. Members of the Software and Technology Vendors Association (SATVA) who work with these issues all the time, have been wrestling with the kind of consent that could be used to disclose records and appropriately specify the degree to which such disclosure is authorized by the patient. Anasazi Software has shared a memorandum of understanding about privacy and security issues related to health information exchange (HIE) in California drafted at their expense. California and some other states have even more restrictive laws than 42 CFR Part 2.
The conclusions in this document lead SATVA members Anasazi Software, Valley Hope Association, and Sequest Technologies to work together to develop and demonstrate to SAMHSA a solution for managing automated electronic health information disclosure. The standardized consent for health information disclosure that they developed could go a long way toward assuring consumer control of their record, at least as that record is represented by the Continuity of Care Document (CCD).
This kind of cooperative effort is one of many reasons of why we at Synergistic Office Solutions are proud to be members of SATVA.
In a previous life, when I was actively involved in the American Psychological Association (APA), I was for three years a member of and one year the chair of the Public Information Committee of the APA. Prior to that, I hosted a live, call-in television show for two years. Frankly Speaking with Dr. Kathy Peres was entirely focused on educating the public about psychological matters. I believe that public education about how mental health issues affect our day-to-day lives is a significant responsibility of all professionals and organizations that provide services in the behavioral health arena.
Given that belief, I was very pleased today to receive an email from the APA announcing a new series of videos and podcasts by APA CEO, Norman B. Anderson, Ph.D. You can view the introduction and the first two installations in the series This is Psychology, one on bullying and another on children’s mental health.
APA invites you to place these links on your own professional web sites and to share them and the information they contain as broadly as possible.
Last week, I wrote about potential problems with use of social media in your organization. Public education of this sort. . .including sharing of the information created on Twitter and FaceBook is one arena in which I think social media has the potential for more power than in any other area of our professional lives.
How does your organization participate in education of the public about behavioral health issues? Please share your initiatives and activities here so others can communicate them more broadly for you.
I am not sure why I continue to attend free webinars about data breaches. They mostly serve to make me extremely anxious for our customers. . . especially for those who have not created a data security plan or have thought minimally about their responsibilities for protecting the privacy of their patients’ Protected Health Information (PHI).
You all certainly know about the requirements that HIPAA and the HITECH portion of ARRA placed upon healthcare providers. You must protect the privacy and security of PHI. You must have assessed the risks to the security of your data and have a plan in place for mitigating any potential consequences of security breach.
The problem is that new potential complications arise all the time. This morning’s webinar was about social media and the potential security risks added by use of those media. It was presented by ID Experts, a company that specializes in an online tool that guides you through handling a data breach when it occurs. They believe that one must assume that such breaches will occur. . . and be ready to react at a moment’s notice.
Do you have a social media policy at work? Are you allowed to use Facebook or Twitter from your work computer? What about from your smart phone paid for by your employer? Are you allowed to access your personal email account from the same computer on which PHI are stored? Today’s presenters talked about all the potential downfalls of such capabilities since most social media sites are not encrypted and have marginally protected security.
I left the webinar feeling anxious for our customers who do not pay attention to these matters. What will they do when they have a data breach? What will you do?
Please share your comments…
The holiday last Monday made it difficult to get to my blog. As each new item that I needed to handle came up, I found myself thinking about what I had hoped to write. Thinking about it was all I managed. No matter how much I thought, I did not discipline myself to leave all the other items aside and write.
Self-discipline is not one of the things I have been short on in my life. I was raised and educated in a setting that strongly taught the need for and benefits of taking responsibility for my own thoughts and actions and shaping them to the way I wanted and needed them to be. The last ten years have included many times when it was harder than ever before to focus myself and move forward, but because I have long known the methods that are most effective for me to achieve self-discipline, I have been able to do so. Taking personal responsibility is second nature for me (except, of course, in the areas where I have complete blind spots!).
For me, this self-discipline has resulted in a strong tendency to take action. . . in pretty much any situation in which I deem action to be necessary. If I have allowed a few extra pounds to creep on, I act to reduce my caloric intake and increase my activity. If I am driving or walking somewhere and have become lost (and don’t happen to have a GPS with me), I ask for directions. If a cause in which I believe is being threatened, I make contributions and write emails. I have always seen it as my responsibility to take action when I could and when it was necessary.
I am currently reading Jon Kabat-Zinn’s book Wherever You Go There You Are. . . one small section at a time. This week, the following paragraph struck me:
What is required to participate more fully in our own health and well-being is simply to listen more carefully and to trust what we hear, to trust the messages from our own life, from our own body and mind and feelings. This sense of participation and trust is all too frequently a missing ingredient in medicine. We call it “mobilizing the inner resources of the patient” for healing, or for just coping better, for seeing a little more clearly, for being a little more assertive, for asking more questions, for getting by more skillfully. It’s not a replacement for expert medical care, but it is a necessary complement to it if you hope to live a truly healthy life—especially in the face of disease, disability, health challenges, and a frequently alienating, intimidating, insensitive, and sometimes iatrogenic healthcare system.
Developing such an attitude means authoring one’s own life and, therefore, assuming some measure of authority oneself. It requires believing in oneself. (My italics)
Most individuals who work in behavioral healthcare are expert at helping others to mobilize their inner resources. This is a large part of what psychotherapy is about. For the seriously mentally ill, helping them see that they have inner resources is significant. . . and a major contributor to the process of recovery.
I have a great deal of difficulty with the large number of people who see the things in their lives going wrong and who feel they can do nothing or who choose to take a passive rather than an active posture. . . but gladly complain about all that is wrong. Listen to talk radio, stand around the metaphorical office ‘water cooler’, shake their heads saying ‘what is this world coming to?’. . . and then go on with their own little lives as if nothing else matters.
I am currently watching this budget debacle unfold in state legislatures (I live in Florida) and Congress. As we all know, the recession and unemployment have resulted in significantly lower tax revenues at every level of government. We have allowed those who represent us to pass laws virtually exempting the wealthy and large corporations from taxation while they rake in the profits. The rest of us continue to pay our sales and property and income taxes, but the working and middle classes just do not earn enough or pay enough in taxes to support the level of government spending that we have all demanded.
The decisions that are being made will most likely result in the deconstruction of the ‘safety net’ that has for the past twenty years provided some minimal care for the chronically mentally ill. As usual, those least able to speak up for themselves will pay the price. . . for the mortgage crisis, unfunded wars, and irresponsible tax cuts.
What is the responsibility of each one of us for the upcoming deconstruction of Medicaid, and possibly Social Security and Medicare? How do you feel about sitting around and complaining vs taking action? Who’s job is it, anyway? Please share your comments below.
A discussion with my coworkers recently reminded me of the wide variability in the size and nature of the organizations that utilize our software products. Behavioral Health organizations range from solo, part-time psychologists, psychiatrists, social workers and professional counselors in private practice to large community-based organizations that provide inpatient, outpatient, intensive outpatient, and home-based care to those requiring mental health and substance abuse treatment.
As a result of this wide variability, the individuals with whom we deal in our provision of technical support services range from highly-trained medical and mental health billing/coding specialists and practice business managers to the teenage child or neighbor of the doctor who happened to be in need of a summer job. We are often amazed by the differences…by how much some billing specialists know and how little information others have.
One of the biggest surprises for me is how often highly trained mental health professionals are willing to entrust their businesses to individuals who have no training to do such a job. We are sometimes asked why our software does not do “x” for them. We explain that the software is a tool to be used by someone who knows mental health/medical billing to accomplish the needed tasks. It will not magically do billing for someone who has no idea how to do that job.
My niece works in a medical practice and is studying for the American Health Information Management Association’s (AHIMA) Certified Coding Specialist – Physician Based exam. I went to AHIMA’s site to see what the content is for this certification and was amazed at the breadth of the knowledge required to achieve the certification. The AAPC is a different organization. . . of professional coders. . . that also offers training, certification, support and networking. Both of these are aimed at individuals who work in medical coding and billing.
Some people who work in behavioral health assume that the billing job must be much simpler for mental health because it contains a much narrower range of services than a general medical practice. Just ask any experienced behavioral health billing specialist, and you will find out that it is not simple at all. Just because the range of services provided in behavioral health is much smaller does not mean that the person doing the billing requires less knowledge about billing and collections and dealing with insurance carriers.
Mental health services were “managed” by insurance carriers much earlier than most other specialties. As a result, there are rules and requirements for obtaining authorization for treatment that have a 30 year history. While “parity” was legislated in 2008 and the final rule for implementation promulgated in 2010, implementation has been slow and many consumers are not even aware that their plan might cover mental health services at the same rate they cover general medical care.
To expect someone who has never worked in a health care setting and has not previously done medical or mental health billing to have any idea about parity or treatment authorizations or copays or coordination of benefits or take-backs is just not reasonable. Medical billing is complicated and behavioral health billing has its own subtleties and complexities that are different.
So what is an employer to do? Here are some quick suggestions:
- Recognize that the person who is doing your billing is running a crucial part of your business. You should expect them to be a business professional.
- Do NOT expect someone who earns minimum wage to know how to do behavioral health billing. If you find a qualified biller who is willing to work for such a wage, they are selling themselves short.
- If your staff is struggling with how to bill, get them information. The Center for Medicare Services (CMS) is an outstanding resource. If a claim will pass Medicare muster, it will also pass the requirements of most other insurers.
- Invest in training for your staff. Having your staff thoroughly learn the software product you are using will earn money for your organization.
This is an arena in which I am sure many of you have experience and opinions. Please share your comments below. If you have additional recommendations for employers, please let us know.
Wednesday, May 18, 2011 is American Psychological Association’s Mental Health Month Blog Party. This post is dedicated to Mental Health and Mental Health Awareness.
This past weekend, we rode 104 miles in the BikeMS Citrus Tour 2011. One of the fun parts of the weekend was getting to spend a few hours with our friend Wayne, one of the people for whom we ride. Wayne and his wife are two of the most positive, forward-looking people I know. While they struggle through the difficult patches that MS dishes out, they maintain a positive, happy focus on life.
As a person who tends more in the pessimistic direction sometimes struggling with depressive emotions, I am always inspired by those who are naturally optimistic and happy or who have set out to become so. Last summer, I read The Happiness Project by Gretchen Rubin and in September, started my own project. While I have not completed the formal project, I learned a great deal in the process.
One of the most important things I learned is that I need to focus on happiness in order to become happier. Unless I make my own happiness and well-being a priority, it will never just happen because of events outside myself. Because of my tendency toward negative thinking and pessimism, I have accepted Gretchen’s offer of a ‘happiness’ quote in my inbox each weekday. The ‘Moment of Happiness‘ daily quotation helps me focus, however briefly, on a thought aimed at Happiness. I have collected a few of my favorites and placed them in a notepad on the desktop of my computer. I love to be reminded each time I turn on my computer of Lao Tse’s statement…one of my favorites since my teen years:
Kindness in words creates confidence.
Kindness in thinking creates profoundness.
Kindness in giving creates love.
—Lao Tse
A new favorite is a quotation from Henry James:
Three things in human life are important:
The first is to be kind.
The second is to be kind.
And the third is to be kind.
—Henry James
Reminding myself of these things daily helps correct my own natural tendency. Giving myself the structure within which to work at happiness helps me to move in that direction.
One of the most important things about this process is that it has effects on both mental health and physical health. Dr. Andrew Weil is a well known integrative medicine expert who has written widely. His blog on Monday focused on the physical health benefits of being happy. Dr. Weil reported on a study in the March 2011 issue of Applied Psychology, Health and Well-Being. The happier and more positive you are, the healthier you are likely to be and the longer you are likely to live. Positive expectations about health events seem also to be correlated with better progress after the events. It appears that working to be happier ourselves can have a significant impact on our physical and mental health.
To go a step further, Dr. Weil suggests that having happy friends is one of the best ways to increase our own happiness. Surrounding ourselves with people who have a positive focus on life and who tend toward cheerfulness can significantly increase our own experience of happiness.
None of these comments are intended to minimize the serious impact that clinical depression has on the lives of those who are so afflicted, but our own thoughts and behavior can reinforce that depression or help improve it. Working to be a happier person and to surround ourselves with other people who are happy can be an invaluable contribution to our own physical and mental health.
We strongly hope that Wayne’s positive attitude will help him stay healthy and even recover some of what he has lost.
Please share your comments below.
Our technical support and customer service staff regularly discuss questions our customers commonly ask. They often answers these questions in emails—repeatedly. For a long time, we have tried to answer some of these questions in documents to make it easier for our customers to succeed in their jobs. The Document Library page on our web site has always aimed to achieve that goal. This year, we implemented new and additional documents in a blog format on our web site as another way for our customers to get answers to their questions quickly.
Electronic claims filing is one of those areas where questions abound. No matter how many times we answer the same questions, we always need to come up with new and different ways to communicate information that is very familiar to us but not so apparent to our customers. This is the same kind of task psychotherapists and others who work with people in any capacity have to accomplish—coming up with different language and presentation of an idea so it can be heard and understood by the person being addressed.
Our lead technical support rep, Manon Faucher, recently wrote an article about how to file claims for secondary insurance carriers electronically. I have borrowed heavily from her article to address the issues that are crucial in successfully filing electronic claims for secondary insurance payers, assuming that the clearinghouse or site through which you send your electronic claims allows submission of secondaries and the payer to whom you are sending can receive secondary claims electronically.
In order to successfully submit secondary insurance claims, it is essential that you include the information about how the claim was adjudicated by the primary insurer. Doing so requires specific data in certain loops and segments of the 837P. If you are an SOS Software user, you should read Manon’s document. She created detailed instructions with screen shots for our product. If you use a different software product, you will need to find out from your vendor whether you can enter and they can report the necessary information to file the secondary claims.
- Primary payer– You must be able to indicate the order of liability for payers. Make sure you have the Primary set as such for this claim.
- Secondary payer– You must be able to designate this payer as Secondary for this claim. You must also be able to enter the “Amount received from other insurance”, information that would go in box 29 on the CMS 1500. This should go into the 2320 loop, segment AMT 02.
- Verify the Claim Adjustment Reason (CAR) amount– If you have received an Electronic Remittance Advice (ERA) that automatically posted your payment from the Primary payer, you will need to determine that the total of the CARs matches the amount of the date of service Fee minus the payment from the primary insurance. Examples:
Denial – no payment by Primary
Fee for service $200
- Primary insurance did not pay for the service so $0 payment is entered for a Denial
CARs must equal the entire fee, $200.00
Partial Payment and Adjustment
Fee for service $200.00
- Primary insurance paid $120.00 and an adjustment of $30.00 was required from the payer
Amount of your CARs will have to equal to $80.00 ($200-$120)
The information from the CARs must be entered in the appropriate segment in the 2430 loop.
- Adjudication or payment date: Make sure you have entered the payment date in the appropriate place so it will show up in loop 2330B segment DTP 03.
- Generate and submit the secondary claim.
If your organization is not yet filing insurance claims electronically, it is certainly a service you should investigate. At some point in the future, it will certainly be required that all claims are filed electronically. In the meantime, it is a major convenience and financial savings for providers and organizations.
Maybe it is time for you to get rid of the paper!
Got any observations, opinions, reservations, cheers about filing claims electronically? Please share in the Comments section below. Thanks for reading!
Just one year ago, after passage of the Affordable Care Act (ACA), The National Council highlighted the expansion of Medicaid that would occur as a result of the ACA. To meet the law’s requirements to provide insurance coverage to the working poor who are generally not insured through their employment, do not have access to insurance groups, and cannot afford individual coverage, the Medicaid program would need to expand to provide the legally required coverage.
In November, the American electorate hired new Congressional representatives who are dead set on rolling back what they call “entitlement” programs (Social Security, Medicare and Medicaid) and returning the Federal government to what they see as its proper role: funder of national security and protector of free markets (code words for defense and corporations). In this new/old world view, individual rights consist of the right to pursue happiness and to bear arms; communal responsibility for one another appears to be non-existent.
Where does that leave those with serious behavioral health issues and the people who treat them?
The National Council works to represent community behavioral health organizations and the people they serve. They view Medicare and Medicaid as crucial to the treatment and therefore to the survival of the seriously mentally ill since “Medicaid is the single largest source of funding for America’s public mental health system.” Since early March, The Council has reported regularly on the threatened slashing of the Medicaid and Medicare systems.
In early March, The Council reported that a group of governors testified about their need for greater “flexibility” in their Medicaid programs. This group especially wanted to be exempted from the maintenance of effort (MOE) requirement under ACA that prohibits the states from rolling back Medicaid eligibility. President Obama said he would support allowing states to opt out of the law’s requirements if they could guarantee an alternative method of providing universal coverage.
On April 4, Representative Paul Ryan (R-WI) released his committee’s plan for the 2012 budget that includes a dramatic restructuring and slashing of both Medicaid and Medicare. On April 7, the National Council released a fact sheet on the potential impact of the funding decreases promised by the budget blueprint. Under Congressman Ryan’s proposal, Medicaid would be converted to a block grant program beginning in 2013 and Medicare would be converted to a privatized voucher system starting in 2022. The House of Representatives voted to adopt this framework. While it is highly unlikely the Senate will accept the blueprint, they will need to come up with one of their own and then work to reconcile it with the House’s plan.
In a Health IT newsletter by Mercom Capital Group, it was reported that on April 14, 2011, The U.S. Department of Health and Human Services (HHS) “announced four initiatives to give states more flexibility to adopt innovative new practices and provide better, more coordinated care for people with Medicaid and Medicare while helping reduce costs for states and families.” In Florida which has been providing some Medicaid services through managed care contracts, the legislature is close to mandating managed care for the entire program in spite of poor reviews for the pilot programs. “At the workshop in Hollywood, a succession of doctors, care providers, advocates and Medicaid patients all had the same message: Managed care has been a disaster.”
As a small business owner who buys health insurance in the private marketplace for a very small group of employees, these proposals are extremely frightening. My health insurance premium at age 60 is already more than the proposed Medicare plan would pay once I become eligible at age 65, and my premiums will certainly not get any lower if I need to buy insurance in the private marketplace. If I, as a pretty healthy 60 year old, am so concerned about these changes to Medicare, I can only imagine the panicky reactions being experienced by those persons represented by the National Alliance on Mental Illness (NAMI) who are dependent upon Medicaid and Medicare to pay for their treatment.
How do you see these proposed changes impacting you and your organization? Do you agree with this method of limiting spending? What ideas do you have for controlling the growth of costs of Medicaid and Medicare? How do you propose that we proceed?
Please share your comments below.
Last week I attended a continuing education workshop for psychologists at my local chapter of the Florida Psychological Association. Psychological Records: Basic Requirements and the (Forced?) Choice of EMRs was presented by Robert J. Porter, Ph.D., president of the Tampa Bay chapter and treasurer of Florida Psychological Association. Dr. Porter’s presentation was attended by about 30 psychologists and other mental health providers. The last FPA workshop on EMRs that I attended was over 10 years ago, and it was given by me. There were about five psychologists present at that workshop.
The difference in attendance speaks to multiple issues. First, Dr. Porter is an excellent presenter who talked broadly about EMRs. His years as a researcher and university professor combined with recent years in private practice give him great credibility. Secondly, the EMR landscape has changed hugely in the past decade with government requirements to migrate patient records to an EMR a distinct possibility.
The psychologists who are my age peers who used an EMR loved computers and liked doing all their work there. Most of our age-mates would never have considered keeping records that could not be locked up in a file cabinet behind their locked office door. The younger psychologists who are now replacing us in the private practice community are not only willing to consider keeping their records electronically. . . they are willing to keep them online using a Software as a Service (SaaS) type product. The move from needing to hold the patient record in my hot little hands to allowing it to float out there in the cloud is a sea change.
While Dr. Porter presented a great deal of information in the two hours he spoke, there were several items I thought you might find interesting.
- The American Psychological Association published Record Keeping Guidelines in the December 2007 issue of the American Psychologist. If you are a psychologist and you keep records, you should read them. If you keep behavioral health records but are not a psychologist, you might take a look at them. Such Guidelines frequently become part of the standard of care in a professional community.
- The APA Guidelines recommend disclosure to the patient of your record keeping procedures, including the limitations of confidentiality of the records. Those limitations of confidentiality lead to a likely need to maintain a separate record of care for each person you treat, including for each individual member of a family or couple. (Guideline 4)
- Ofer Zur, Ph.D., a licensed psychologist in California, offers extensive information about and continuing education on record keeping and many other aspects of behavioral health practice. [Retrieved 4/19/2011 from http://www.zurinstitute.com/recordkeepingguidelines.html.]
- Dr. Zur points out that a treatment plan usually includes problems or symptoms, a diagnosis, goals of treatment, interventions to be used to achieve the goals, and the rationale for use of those interventions.
I would add a quick note about the possibility of a requirement to keep records of psychological care in an EMR. At present, the only behavioral health providers who are Eligible Providers (EP) for ARRA funding to purchase an EMR are psychiatrists and nurse practitioners. Psychologists, social workers, mental health counselors and addiction professionals do not qualify, nor do psychiatric hospitals. While this may change, there is currenly no way for most mental health providers to obtain stimulus funds. At the same time, there is no requirement for them to move to an EMR, nor will they be penalized for not doing so (psychiatrists and nurse practitioners may be subjected to Medicare withholds). Fortunately, most of the products aimed at the private mental health practitioner are relatively inexpensive and can easily be obtained without resorting to government funding or a second mortgage on your house.
While an electronic medical record can be a powerful way to significantly increase the quality of the records maintained by you and your organization, you must know what you are required to maintain in the record. . . by the governmental jurisdictions and the professional guidelines to which you are subject.
How does your organization determine what goes in the client’s record? Who is responsible for those records? Are you using an EMR, a paper record, or some hybrid system?
Please share your thoughts on records in the Comments below.
Do you have a favorite author?
I have loved different writers at various times in my life. At present, one of my favorites is Barbara Kingsolver. What? You don’t know her work? Well, you should try one of her best known, The Poisonwood Bible, the story of a missionary family in the Congo in the late 1950′s. Or perhaps you would like her first novel, The Bean Trees, the tale of a young woman escaping rural Kentucky to establish her life as an independent woman. Those of you interested in eating locally and creating a more sustainable natural future for us all would enjoy one of her non-fiction titles, Animal, Vegetable, Miracle.
This past weekend, we attended Seth’s 40th reunion at Duke University. The only event I was intent upon attending was the presentation of the LEAF award granted by the Nicholas School of the Environment for Lifetime Environmental Achievement in the Fine arts. This year’s award was given to Kingsolver. I was hoping to hear something inspirational from this wonderful writer. I was not disappointed. Her reading from Prodigal Summer, one of her books I have not read, reminded me of her powerful ability to poignantly describe the natural world and our place in it. That one has moved to the top of my reading list.
The Dean of the Nicholas School, Dr. William L. Chameides, in addition to his administrative and teaching responsibilities, writes a blog called The Green Grok. As best I can tell so far, it is a wonderful source of factual environmental information and inspiration toward sustainable living. I am a new subscriber.
On Sunday we spent a few hours in the Sarah P. Duke Gardens. What a wonderful setting this is! According to the garden web site, this beautiful place was built in a debris-filled ravine…truly a recovery of the land to its best possible use. While I will never create something of such beauty as the Duke Gardens, my visit there inspired me to return home to beautify my own surroundings, to assure that the vegetables I have planted thrive, and to thoroughly enjoy the bird life on our property. My own contribution to the natural world, its protection and preservation may be small, but it is heartfelt. I am grateful for the inspiration of artists and naturalists to keep me going in my bit of work to enhance my natural surroundings.
As a professional who has worked in and with behavioral health organizations for 35 years, I strongly feel the need to encourage a focus on the natural world as a primary way to improve our mental health. I returned home with a renewed focus of that imperative.
What do your favorite authors inspire in you? Please share your comments below.
Once a month, on average, our technical support specialists are confronted with a customer whose database has become corrupted because of some hardware issue and who has no usable backup. After last week’s adventure, I decided I would again write about backup. Then, last night, I saw a discussion on a Psychology and Technology listserv that included some of our customers talking about full disk encryption of a Mac laptop. Encryption is something we recommend for every customer who uses our software or maintains any Protected Health Information (PHI) on a computer…especially on a laptop. To round out the clues that security and backup should be my topics of choice this week, I noticed an article in eweek of March 21, 2011 entitled ‘Remote access presents complexity, security issues.’
The rate at which users want to be able to access their work applications remotely has grown geometrically. Fifteen years ago, we were asked about remote access a couple of times a year. Five years ago, that increased to a couple of times a month as many more users wanted to be able to access their software from home. Now, everyone who carries a laptop, or even a smart phone, wants to be able to do everything they need to do for their jobs from wherever they are located with whatever device they have handy.
Whew! If only they realized what an expectation that is! And, all of these expectations complicate the issue of security in ways that those of us who are not very technically savvy cannot imagine. But imagine we must…if we plan to protect PHI, that is.
First, the issue of backup. This is the primary way in which you protect the security and integrity of client information. If you do not have a usable backup from which you could restore PHI in the event of a catastrophe, you are only one step away from having allowed the destruction of your client’s PHI.
Yes, the identifying demographics together with the diagnosis you use to file claims is PHI and is protected under HIPAA. Everything you have in an EMR is PHI. Yes, you are responsible to assure that this information is intact, safe from destruction, and secure from preying eyes (and hacks). Without a usable backup (preferably encrypted) stored in a secure location ready at a moment’s notice to replace data on your computer system, you are not even doing the most basic things necessary to provide protection to your patients. You could probably be demonstrated to be guilty of ‘willful neglect,’ the level of culpability that will generate the highest of fines from HHS and OCR under their HIPAA authority.
If you are not sure of what kind of backup strategy is minimally adequate, take a look at the backup recommendations and product suggestions we make to our customers.
The issue of remote access, especially from handheld devices like smart phones and iPads, is one that concerns me considerably. HIPAA requires that we must provide for the security of PHI while it is at rest (on a computer drive or CD or smart phone) and while it is in motion (being transmitted from one location or device to another).
Access tunnels like a secure VPN or MS Terminal Services are specifically designed to assure the safety and security of the data being transmitted through those tunnels. Those of us who are not very technically sophisticated may assume that the developers of the iPad and smart phones have already taken care of equivalent security for us. Not so, folks. While there are some products that will provide that security, they are not built into those hand held devices and we are on our own to find them.
Do you realize what that means? Do you understand that using your cell phone to access your desktop computer and patient information without adding specific protection assures that your data are vulnerable? There is not built-in security in your telephone or tablet. Even having your client names and phone numbers in your telephone contact list is potentially a breach of their privacy.
No one has volunteered to create a secure environment for your data…that is your job. You must do the research and determine which products will give your PHI the greatest protection.
Not being informed about a problem of insecurity is not considered an excuse by HIPAA. You must know what security your devices use to assure the safety of PHI. Do you have password protection on your phone? Do you have a way of wiping all data from the phone if you lose it or it is stolen? Have you initiated the services that are available to accomplish those purposes?
I know, this has started to sound like a rant. I do not mean to suggest that everyone is acting irresponsibly with client PHI. I do mean to suggest that we take a much too casual attitude toward protection of that PHI…especially when it comes to technologies about which we know little but assume much.
What policies does your organization have in place about use of portable devices and the protection of PHI? Have you found products that are wonderful to accomplish that protection? Will you share their names and your experiences with the rest of us?
Please enter your comments below.
Two nights ago I woke up at 1:30 a.m. and did not fall back to sleep until 3:30 a.m. The room was too hot to sleep comfortably and I was awakened by a night sweat. I got up and cooled the room, but before I could fall back to sleep I was experiencing painful flushing caused by the niacin I take. Yikes! Today I am struggling with staying awake and trying to be productive.
According to surveys done between 1999 and 2004 by the National Sleep Foundation, 60% of adults report having difficulties sleeping a few nights a week. According to WebMD, some of the consequences of sleep deprivation can be:
- Decreased performance and alertness
- Memory and cognitive impairment
- Stress on relationships
- Poor quality of life
- Occupational injury
- Automobile injury
For many of us, irritability, poor decision making and decreased performance are the main problems. Yep, I have now started this article for the second time…my first try did not save properly.
According to sleep researchers, cognitive behavioral therapy can be as or more effective than the use of popular medications to solve sleep issues. Some of the recommendations for improved sleep include this list from the APA web site:
- Keep a regular sleep/wake schedule
- Don’t drink or eat caffeine four to six hours before bed and minimize daytime use
- Don’t smoke, especially near bedtime or if you awake in the night
- Avoid alcohol and heavy meals before sleep
- Get regular exercise
- Minimize noise, light and excessive hot and cold temperatures where you sleep
- Develop a regular bed time and go to bed at the same time each night
- Try and wake up without an alarm clock
- Attempt to go to bed earlier every night for certain period; this will ensure that you’re getting enough sleep
I will definitely be heading to bed early tonight. I already do many of the other recommendations and usually sleep pretty well. Maybe that is why I am so discombobulated when my sleep is disturbed.
How often is sleep deprivation a problem for you? Has it become chronic insomnia? What do you do about it? How can we prevent this epidemic of sleep deprivation from undermining our lives?
Please share your experiences, your comments, your yawns 
below.
Many of our customers include Case Management as part of the mix of services provided to clients. Among the seriously mentally ill (SMI) population, Case Management has become an essential service helping individuals gain the most from the services they receive. Helping the client take their medication as prescribed, assessing their current symptom status, intervening to alter treatment rapidly if a crisis is looming are all functions that Case Managers provide. These services are provided both in-person and by telephone.
A new study published in The Journal of General Internal Medicine suggests that email contact with a trained psychiatric nurse can dramatically improve the outcome of medication treatment for depression by internal medicine practices. Reported in Healthcare IT News on March 17, the study was a follow-up to a similar study using telephone contact with patients who had newly been started on antidepressant medication. According to the report, the email messaging was even more effective than a telephone call in improving the benefit of the medication.
The study utilized 208 members of Group Health, a consumer-governed, nonprofit, integrated healthcare organization that coordinates care and coverage for 600,000 individuals in Washington state and Idaho. The Group Health Research Institute (GHRI) was the responsible research organization. GHRI is a non-proprietary, public-domain research institution within Group Health.
The Group Health plan includes a patient portal that has access into the organization’s electronic health record. According to the abstract of the article, the Intervention consisted of:
Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record.
This study was motivated by poor improvement outcomes reported nationally for depressed individuals treated by their primary care providers with antidepressant medication. The goal of the entire research project is to determine if use of an organized plan of treatment including evidence-based follow-up services would result in greater effectiveness of medical therapy.
A significant movement is developing within the U.S. to improve outcomes of our healthcare system by providing services in non-traditional ways. The Connected Healthmovement seeks to improve healthcare services and outcomes by use of technology to remotely monitor and provide services. Partners Healthcare Center for Connected Health has been a pioneer in this effort. Their web site states the goal in this fashion:
Changing Healthcare Delivery
We are engaging patients, providers and the connected health community to deliver quality care outside of traditional medical settings. Telehealth, remote care and disease management initiatives reflect the opportunities for technology-enabled care programs.
What potentials do you see for the use of electronic methodologies like secure email communication with clients within your organization? Are you already engaged in such endeavors? What do you see as the obstacles to such care? What are the potential benefits to your clients? How do we get from here to there?
Please share your experiences, concerns and other comments below.
