Teleheath, eHealth, and Outsourcing: Where are we going?

When the number of articles coming through my inbox converge on a topic, I usually decide it is time to write about it. Three articles about telehealth and e-health appeared today. Another dropped into my inbox at the beginning of July. What is this about and what does it have to do with behavioral health organizations and practices?

As you are undoubtedly aware, what happens in the broader healthcare community often follows in the behavioral health world. Sometimes behavioral health leads the way with innovations; at other times it merely follows. Telehealth is one arena where I think behavioral health has been in the vanguard.

I would like to start with three simple definitions:

  1. Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. (from
  2. eHealth (also written e-health) is a relatively recent term for healthcare practice supported by electronic processes and communication, dating back to at least 1999.[1] Usage of the term varies: some would argue it is interchangeable with health informatics with a broad definition covering electronic/digital processes in health[2] while others use it in the narrower sense of healthcare practice using the Internet. (from Wikipedia)
  3. In business, outsourcing is the contracting out of a business process to a third-party. The term “outsourcing” became popular in the United States near the turn of the 21st century. . . Outsourcing includes both foreign and domestic contracting,[3] and sometimes includes offshoring or relocating a business function to another country.[4] Financial savings from lower international labor rates is a big motivation for outsourcing/offshoring. (from Wikipedia)


I have included these three terms together because outsourcing often goes with the capability of using electronic devices and various telecommunications methods. Certainly, most of us have some experience of receiving customer service assistance from somewhere half way around the world from our homes. I am wondering if the same will be true as we move toward increasing the use of telehealth and ehealth methods in our healthcare system.

Two of the three articles I saw today related to general healthcare. FierceHealthIT newsletter contained two articles about the potential benefits of electronic doctor visits and telemedicine. With pressure on insurance payers and employers to provide healthcare services at lower cost than currently, we can expect all sorts of innovations. The capability of ‘seeing’ patients remotely is one of those possible innovations.

But what about behavioral health? And what does outsourcing have to do with any of this?

In yesterday’s Open Minds daily briefing, Monica Oss discussed telehealth and how it is beginning to spread in the behavioral health world. With Medicare now willing to pay for telehealth services that meet certain criteria, this possibility has become more likely. In behavioral health, telephone contact with clients has been a long-time staple in helping clients remain stable. Now that Skype and other visual telecommunications capabilities exist, a whole new industry has developed . . . and many existing organizations have added ways to include remote psychotherapy and follow-up sessions in the repertoire of their organizations. SAMHSA and HRSA have pioneered projects and pilot programs to foster such development, especially into rural communities.

Where there is remote capability to provide services, outsourcing is not far behind. If it can be done more cheaply by using resources outside the U.S., businesses will find ways to do it. While licensing and practice laws may currently stand in the way of too much outsourcing, you can be sure that it will come.

How does any of this affect your behavioral health organization? Our experience with our customers suggests that change occurs very slowly within their organizations.

As those of us who are more senior slow down our participation and eventually retire, resistance to paradigmatic change reduces. As younger people who are perfectly comfortable with all things electronic move into the professional arena, newer technologies are successfully introduced. Where is your organization in this process? Do you see groundbreaking changes ready to happen? Or is your organization one of those holding onto the older ways at all costs?

Please share your opinions and experience with telehealth services and where you see it going. And what about outsourcing? Just click in the Comment box below to share your thinking.

Brain Training: What is it and does it work?

In July, I spent ten days at an ashram taking an immersion program in preparation for yoga teacher training. In this particular tradition, the teacher is provided with a script that must be memorized prior to certification. The program is structured to maximize learning the script, but I have found myself stressed to my utmost in my efforts to memorize this sequence of 29 postures and the two paragraphs of instructions that go with each one.

Memorization has never been my favorite type of learning. It is good that I did not need to memorize too much to complete my Ph.D. Comprehension is my strong suit. I am great with concepts…learning and expressing them. I am not so good with word-for-word memorization. As a student, I did this by repetition and rehearsal. I did oratory and debate in high school and, with lots of work, I was able to memorize my speeches when appropriate. Besides, I had written them, so they were my thoughts and words. Memorizing my lines in a play was always harder. Memorizing lists of terms and their definitions was my least favorite, but usually successfully done task.

Then my brain aged. Thank goodness for that; it certainly beats the alternative. However, the aging of my brain has manifested itself most obviously in struggles with remembering things. I use a reminder app on my telephone for day-to-day things, and it is very effective. I use a calendar with alarms for appointments. I do not usually miss things I have scheduled or reminded myself to do. But memorizing a large number of someone else’s words is proving to be very difficult for me.

In June, Monica Oss of Open Minds wrote an article summarizing some of the presentations and discussion at their June 2014 conference Technology for Better Brains: The Rise of New Treatments Based on Brain Science Innovation. The presenters were from Neuronetics, providers of Neurostar TMS Therapy® (Transcranial Magnetic Stimulation) and the Center for Life Management, an organization that uses this system; Brain Resources, Inc., a company that markets assessments and brain training tools; and Posit Science, the developers of brainHQ. Obviously, these individuals are all selling something, so I would want to know a bit more about the science before I buy.

In February, we had a visitor who had a concussion last Fall. She is a physician in her late 50’s who was told to rest her brain entirely to allow it to heal and recover. After a couple of months of rest, she was allowed to begin some brain rehabilitation. Now, she does brain exercises daily at a website called She has found them to be most helpful. I take this first hand experience seriously coming from a physician who does not have a vested interest in the process.

I have not yet signed up for their program or any of the others, but I am very curious. I wonder what experience and information any of you have about these systems. I know we have neuropsychologists who read this blog. What is your take on brain training? Does the science support the sales? My ailing memory wants to know!

Please share any information or experience you might have with any brain training systems or with Transcranial Magnetic Stimulation. Just enter your comments below.


SAMHSA Listening Session Important for SA Providers

The Substance Abuse and Mental Health Services Administration (SAMHSA) will be holding an all-day listening session on June 11, 2014. During that session, they will hear input from stakeholders about possible changes to the regulations that govern 42 CFR Part 2 controlled organizations. If your organization provides services to chemically dependent and recovering individuals, it might be useful for you to listen in on this session.

Event Details

The Substance Abuse and Mental Health Services Administration (SAMHSA) announces that it will hold a public listening session to solicit information concerning the Confidentiality of Alcohol and Drug Abuse Patient Records Regulation, 42 CFR Part 2. These sessions will be held in Rockville, MD to obtain direct input from stakeholders on updating the regulations. The scheduled listening session provides an opportunity for SAMHSA to seek public input on potential changes to the regulations.

The session is open to the public and the entire day’s proceedings will be webcast, recorded, and made publicly available. Interested parties may participate in person or via webcast. Capacity is limited and registration is required. Registration will be open until we meet maximum capacity. The forum will begin with opening remarks from the SAMHSA official charged with moderating the session. The session location is accessible to persons with disabilities.


Do register if you have concern about confidentiality and 42 CFR Part 2, or just want to learn more.

Vacation Time: Storm before the calm

It is time for a vacation. I feel like I have been racing around for the past year. I am not sure why things got even more hectic once I no longer had caregiver responsibilities, but they did. Perhaps I have spent the year trying to catch up and get back to being productive. Now I am beat!

I have never learned the skill of getting away for vacation without working lots more before and after the trip. Especially as I get older, I think about things that really should be taken care of before I leave…just in case. Perhaps some of you have suggestions for me. I would love to be able to get away without so much stress! Please share your ideas. My mental health is at stake.

In any case, this blog will be on hiatus for the rest of May while I try to reinvigorate myself. Please enter your comments below.


Single Payer Systems: U.S. Medicare and Canadian Medicare

I don’t know about you, but I often read a brief article that draws upon another. Sometimes those secondary articles are excellent in their own right. Sometimes, going to the original is the only way to actually get the original author’s slant.

Wendell Potter is a former Cigna executive turned whistle-blower on the private insurance industry in general and HMO’s in particular. In his position as Vice President of Corporate Communications, he participated in what he now considers disinformation about healthcare single payer systems and the U.S. insurance industry. He now works for the Center for Public Integrity, speaking and writing extensively.

An article Potter recently wrote, The Canadian health care system I disparaged, was cited in FierceHealthPayer, a newsletter I read regularly. Single-payer traits worth emulating found two such qualities the Canadian system would benefit from:

  1. Make their system more consistent across provinces, as does the U.S. Medicare system. Currently, Canadian Medicare operates like U.S. Medicaid in that the province has great discretion about the benefits provided, just as the states do with Medicaid.
  2. Provide prescription medication coverage like Medicare Part D. At present, Canadians must purchase separate insurance if they do not want to pay the entire cost of prescriptions out of pocket.

The Canadian system covers everyone; U.S. Medicare only covers those 65 and over, and some disabled individuals. In his article, Mr. Potter apologized to Canadians for his years of disparagement of their system. He noted that he and other insurance industry representatives routinely presented exceptional cases as the norm, denigrating the Canadian system. In his travels and speaking in Canada, he “didn’t encounter a single Canadian who didn’t talk about their Medicare program with pride”.

Over the course of a two-decade career as a health insurance executive, I spent hours and hours implementing my industry’s ongoing propaganda campaign to mislead people about the Canadian health care system. We spread horror stories about “rationed care” and long waiting times for medically necessary care. Our anecdotes were not at all representative of most Canadians’ experiences, but we spent millions of dollars to persuade Americans that they were.

FierceHealthPayer indicates that

Experts from Canada, Denmark and other countries have maintained that a U.S. Medicare-for-all system would alleviate high administrative cost. In Canada, administrative costs average 1.3 percent, well below the average 31 percent for the U.S. healthcare system, Danielle Martin, M.D., vice president of medical affairs and health system solutions at Women’s College Hospital in Toronto, Canada, told the Subcommittee on Primary Health and Aging last month. Martin also addressed U.S. concerns about socialized medicine, explaining that in Canada, insurance is public and hospitals and providers are private entities.

How would your organization function differently if there were a single payer for all services, covering your behavioral health services at the same level they are covered now (averaging across your current payers)? Would such a system work better or worse for you? I know what my answers are to those questions. I wonder what yours are. Please enter your comments below.


Anxiety, Anticipation, Excitement: Prelude to . . .

Have you ever found yourself anxious prior to an event to which you have been looking forward? Do excitement and anticipation blend into anxiety for you? Or vice versa? Can you shape anxiety into a more positive anticipation and even excitement?

I find myself approaching a vacation that I have been planning and looking forward to for months. We are doing the trip as I would prefer…without bicycles. We are going to the cities I have wanted to visit and engaging in many of the activities I choose.

That is not to say that the inclinations of those with whom I am traveling have been ignored. They would prefer not to be in museums all the time, and not to be scheduled every moment of every day. There are so many things that I want to do and see that I could happily go from one to the next to the next if I were on my own (and if my feet held out). Since I am with others, I have scheduled us for things that require it and generated possibilities for the rest of the time.

This has caused lots of anxiety for me. I am a people-pleaser in my core makeup. I work to assert my needs and desires, but I also want those around me to be happy. Needless to say, this causes anxiety, ambivalence, frustration. The planning process has been a stressful one.

I am always fascinated by the internal experience of a set of emotions. Like many people, I have been very anxious since I was a child. Research on DSM diagnostic categories indicates that Anxiety is easily the most common of emotional difficulties experienced by the U.S. population. I fit right in there.

As a child and teenager, I just pushed through the anxiety in order to accomplish the goals I had set for myself. As a young woman, I learned that I could reinterpret my anxiety, choosing to see the physical agitation, increased heart rate, sleeplessness and other physiological signs of arousal as excitement, thereby giving it a positive meaning rather than the negative connotations of anxiety.

As an older adult, I find it harder to manage the experience of anxiety. My yoga practice helps me feel better at the time, but I have not been successful at carrying the relaxation and positive mental state over into the rest of my day. The agitation causes stress in my relationships. I have a harder time not snapping at those closest to me. Sleep disturbance makes that even worse.

I certainly need to get this in check or I risk messing up my enjoyment of my vacation!

How do you deal with anxiety? Is medication your route? Or meditation? Go for a run? Do you have methods that I might learn…quick? Please share your comments below.

Turbulence Ahead in the Behavioral Health Marketplace

I recently found myself thinking . . . again . . . about changes in the behavioral healthcare marketplace and wondering how our customers are doing. A couple of weeks ago, Monica Oss of Open Minds wrote about dramatic changes in reimbursement methods in the public behavioral health sector in New Jersey and how organizations there are adapting and positioning themselves. We have been watching our larger customers go through multiple changes in how they are structured and how they serve clients over the past five or more years; simultaneously, most of our smaller, private practitioners seem to have made few changes in how they provide services.

Ms. Oss lays out some of the payment issues very clearly:

The reasons for the shift away from fee-for-service (FFS) reimbursement are many and the emerging value-based payment and pay-for-performance (P4P) payment models are many and complex. But the challenges for executive teams, regardless of the emerging payment model in their market, fall in two categories — market positioning for future sustainability and competitive organizational performance.


At the front end, a focus on markets and business approaches to practice turns many small providers off. They do not want to recognize or address the fact that they are running a business and that doing so takes thought and consideration about their market and about how they measure up compared to others who provide the same services. They see themselves as helpers, not as business persons. On the other hand, failure to be informed about transformations that are rapidly occurring and where they will fit into the altered professional environment, will likely leave them stranded in a practice that is slowly dying.

One of the most profound of the emerging changes is the integration of behavioral health and physical health services into one setting.

Since my own training is as a psychologist, I decided to take a quick look at what American Psychological Association (APA) is promoting to its members to help them prepare for and address the dramatic modifications that are likely coming in mental health service delivery. At first glance, I was pleased to see that the organization has developed a Center for Psychology and Health. I do recall that this was a major push of my friend and colleague Suzanne B. Johnson, Ph.D. when she was APA President. But it took some patience and searching to find any meaningful information.

I visited the APA website, but had to read the small print three-quarters of the way down the page to get to the first mention of the Center for Psychology and Health. Once I navigated to that page, the first thing I saw there was ‘Health Psychology CE Programs.’ I had to push past my hesitation (because I am not a ‘health psychologist’); I read around the rest of the page and found a few things that looked hopeful, but only found those under the headers ‘For Students and Educators’ and ‘For the Public.’ An article entitled Moving into Primary Care was hidden behind a link named ‘Five ways to collaborate with physicians’ in the ‘For the Psychologist’ section. On the other hand, an article named ‘What is Integrated Care?’ was listed under ‘For the Public.’ The information would be quite appropriate for professionals who are wanting to have an understanding of just what this integration of mental health care and general health care is really all about.

When I went to the website of the APA Practice Organization, I was more disappointed. I found no headers about integrated care or pay for performance. When I used the search box for those terms, I did find some articles. Unfortunately, only one was recent (2013). The next most recent article was written in 2009.

The website of the National Council, on the other hand, has easily-found, current information about their Center for Integrated Health Solutions, a joint project with SAMHSA. Clearly, the public behavioral health community is rapidly moving in this direction.

I am afraid that psychologists and other private practice mental health professionals might be having a difficult time figuring our where they might fit into a different kind of marketplace, or even that a different kind of marketplace is on its way, because their professional associations are doing a terrible job of helping them conceptualize and create the alternative practice structures that will be needed to survive in this turbulent arena.

What is your organization doing to redefine, re-position and reinvent your practice to assure that you will thrive well into the future? Please share your comments below.

Encryption of Backups: Must I?

A few weeks ago, Seth Krieger, President of SOS and our own HIPAA Privacy Officer, was asked a question about encryption and backups. Since we are regularly faced with behavioral health organization customers who have no backups and many others who have questions about HIPAA, I thought you might be interested in this brief Q & A.

Question: “Does HIPAA require local backups to also be encrypted?”


There are no HIPAA rules that explicitly require encryption anywhere, but there certainly are severe penalties for failure to secure data, and a provision for a safe harbor if the data is encrypted. That is, if media containing protected health information (PHI) should be stolen, you are in a world of hurt. There can be fines; required publication of the breach in the local newspaper (if the breach includes over 500 patients); mitigation of potential identity theft by purchasing identity theft protection policies for all patients; impact on your reputation in the community; potential civil suits and criminal prosecution; etc.

On the other hand, if the data you lose is encrypted, HHS does not regard it as a breach. The rule explicitly states that the loss of encrypted data does not constitute a breach, so you are not required to report it, or to notify your patients in any form.

That, friends, is a giant carrot, dipped in chocolate!

Let’s review: If I don’t encrypt all my media containing PHI (including the hard drives in my computers, flash drives, and backups), I could face major, major losses, starting with some pretty severe fines but potentially so damaging that the practice might not survive. Alternatively, I could follow some easy encryption steps and be the proud owner of a cloak of invulnerability (where data breaches are concerned). Tough choice, huh?

Because backup media are, or should be rotated to an off-site location, they could be lost or stolen much more easily than media inside of servers and REALLY should be very high on the encryption list. The easiest way to go is just to use backup software that provides an encryption option. Most every commercial backup software has such an option. All you have to do is to check the box and type in a password. In most every case, that choice becomes part of the configuration and will be automatic for every future backup you do with that software and backup configuration. Easy!

That is not to say that a stationary drive need not be encrypted — it absolutely does. The low hanging fruit here, however, is any media that travels. Every phone, laptop, tablet and flash drive should be encrypted if there is any chance at all that it could contain PHI. Think in terms of patient telephone lists, letters, reports, acknowledgements to referral sources, practice management software, etc. Electronic Medical Records are not the only place you might have PHI that you are required to keep secure and private.

For more thoughts and advice regarding encryption, please see this earlier post:

Get Out of HIPAA Jail Free

Here are some others on related subjects:

The Devil and Database Encryption

Mobile Data Security a Big Concern

Please share how you have used encryption to secure your cloak of invulnerability!

Congress Throws a monkey wrench into ICD-10 Implementation

I don’t know about you, but I am tired. I am tired of being told U.S. healthcare costs too much for too little, but the powers-that-be not having the character to do what is necessary to change it. I am tired of the Affordable Care Act being blamed for all the faults in our health system. I am tired of steps being organized and taken by an entire industry to move toward modernization only to have a group of power-mongers throw the work out. I am tired of politics being played with our healthcare system.

Nothing I have read has any real explanation for why Congress has delayed implementation of the ICD-10. One article suggested that some groups of physicians were rewarded for something that is not at all clear. Since many other physician and industry groups are strongly opposed to such a delay, it is difficult to see what the gain is. Most have no real idea why a delay in ICD-10 implementation was added last week to yet another temporary fix to the Medicare Sustainable Growth Rate (SGR) fix, referred to by the media as the ‘doc fix’.

In fact, this decision throws the work of the many players into question. CMS has said they will step back. study the rules, then decide what to do. But what about those in private industry. The insurance carriers and clearinghouses, the hospitals and physician practices, software vendors and software users, those training billing coders and those doing the billing…all who have been working hard to be ready to start using ICD-10 diagnosis and procedure codes on October 1, 2014. It might be costly to make this switch, but dragging it out for another year has just increased the cost. and those of us who are paying that cost are not getting any help from our elected representatives.

I, for one, would vote in a heartbeat for a single-issue candidate whose purpose was a single-payer healthcare system…one payer, one set of rules, one set of expectations to meet!

And, oh yes, you must use the new CMS 1500 claim form, version 02.12, to file your claims. Just be sure to keep using the ICD-9 codes on the claims.


Simply Put: Simplify

A bit over a year ago, a couple of weeks after the death of my mother, I received an email from a blog entitled ‘Becoming Minimalist.’ I don’t know why I received it; I do not remember expressing interest in the topic of removing possessions as the driving force in my life. I like to think that someone who knows me sent it to me because they knew I need it.

I read the post and created a folder called ‘Simplify’ to save the ones I liked. I have not even developed the habit of reading the posts when they arrive in my mailbox each week, but I know that I have that as a goal and have them there whenever I am ready to dig in. Just seeing the email arrive reminds me that I also have as a goal to simplify my life.

When I received today’s post, I was reminded again of something I learned a long time ago but seem to need regular lessons in. The lifestyle I live often gets in the way of the lifestyle I think I want to live. As I once learned in a Twelve Step program, I behave as if I am a human doing rather than a human being. Part of the reason for that is that I have placed so much importance on success in my job and the ownership of nice things. I think I must be constantly doing in order to maintain what I have and get more of the same. That is not really all I want in life, but it is how I behave.

When I was a child, I learned that developing different patterns of behavior took a constant focus on that new pattern and practice of it. As a psychologist, I taught clients how to do that. In my daily life, I forget that over and over again. It is as if I never learned how to change one habit and create a new one. Had I read the post I received last Friday, I would have been reminded again that there is a science to change and we can all accomplish it.

Part of the reason for my ongoing re-learning of these lessons is that I usually focus outside myself rather than inside. While I have always experienced an internal locus of control (for all you psychology-types), I have for some reason spent my energy on behaving to a certain effect in the world rather than on regularly re-confirming a commitment to a certain way of being and developing the patterns of behavior which accomplish that.

I did better when I was a therapist; helping others learn to decide what they want to be and to behave in that direction helped me do the same for myself.  What do you do; what circumstances do you create that allow you to become more of the person you want to be each day? Your comments and suggestions are welcome.


Performance-Based Compensation: What is your plan?

If you are a solo provider of mental health services in private practice, you entire income is based on your performance as a psychotherapist or diagnostician or prescriber. There is really nothing between you and your patients. You see them; they are satisfied and continue coming to see you, or they are not and do not return. That is ‘performance based compensation’ of the most basic sort. I have often wondered precisely what others mean by that term.

Earlier this week, I read an article by Sarah Threnhauser of Open Minds that very much enlightened me. Making Performance-Based Comp Plans Work is an excellent look at the compensation plan of Manatee Glens, a specialty hospital and outpatient program in Bradenton, Florida. The article discusses the criteria they use for measuring performance as well as the steps they follow to measure each clinician’s functioning relative to the criteria. One of their measures is number of client no-shows; another is clinician completion of concurrent documentation with the client. Surpassing the criteria results in additional pay to the clinician.

Does your organization use any sort of performance-based compensation? How have you made it fit the personality and structure of your practice or agency? What kinds of functions do you measure? What criteria do you use?

Please share your comments and responses in the comment section below. We would love to have our discussion here on this blog site!


Government Entities are not sheltered from HIPAA requirements

For the first time, the Office of Civil Rights (OCR) has levied a fine against a government entity for a possible HIPAA breach.

Skagit County, WA, a small county (118,000) in the northwest part of the state, was fined $215,000 for its failure to protect patient information controlled by the county Health Department. Even after a data breach in 2011 that the county reported to OCR, the county failed to implement adequate policies and procedures to prevent future breaches.

In its report about this incident, FierceHealthIT also cited the compromise of information for 169,000 clients served by the Los Angeles County Department of Health Services. A third party billing vendor, Sutherland Healthcare Solutions, was the victim of theft of unencrypted computers containing the not-so-protected PHI of these clients.

If you think that being small or a government entity or a not-for-profit might protect you from being penalized for the exposure of the data of your clients, best that you think again. We are all responsible for assuring that PHI is protected, whether the people involved are our own clients, or in the case of SOS, the clients of our customers who are Covered Entities. This is not an area in which you should skimp on effort made to protect information.

Please share with us and your colleagues some of the steps you have taken to assure the protection of the PHI of your clients. Do you feel that your written policies and implemented procedures are known and understood by your employees? Do they take these procedures seriously? What do you do when you learn that they are not practicing what they have been taught? When was the last time you had training on HIPAA issues? You do have training, right?

Please comment below.

Sharing Mental Health Information: HIPAA Privacy Rule Guidance

Those of us trained as providers of mental health services have been indoctrinated about the need to maintain the privacy of our patients. Unfortunately, changes in law and in rules mean that the way in which we were trained may no longer fit the realities on the ground. It is essential that you stay up-to-date on the requirements of your state (especially if those requirements are more stringent than HIPAA) and on the requirements of HIPAA for protecting the privacy of your patients.

The Office of Civil Rights (OCR) and Health and Human Services (HHS) has issued Guidance regarding the HIPAA Privacy Rule and Mental Health information. This is information you will want to read. The Department specifically addressed issues that are directly pertinent to behavioral health providers of every ilk.

In this guidance, we address some of the more frequently asked questions about when it is appropriate under the Privacy Rule for a health care provider to share the protected health information of a patient who is being treated for a mental health condition. We clarify when HIPAA permits health care providers to:

  • Communicate with a patient’s family members, friends, or others involved in the patient’s care;
  • Communicate with family members when the patient is an adult;
  • Communicate with the parent of a patient who is a minor;
  • Consider the patient’s capacity to agree or object to the sharing of their information;
  • Involve a patient’s family members, friends, or others in dealing with patient failures to adhere to medication or other therapy;
  • Listen to family members about their loved ones receiving mental health treatment;
  • Communicate with family member, law enforcement, or others when the patient presents a serious and imminent threat of harm to self or others; and
  • Communicate to law enforcement about the release of a patient brought in for an emergency psychiatric hold.

The Question & Answer format is a helpful way to quickly review the relevant information. You might take particular note of the section on the protection of psychotherapy notes. Some providers have chosen to believe that any note they write about the psychotherapy provided is protected and that they do not have to release such information when it is requested. This Guidance spells out what this does NOT mean. In other words, it specifies all the information that is not a ‘psychotherapy note’ for the purposes of the rule. You might be surprised to find, for instance, that symptoms, prognosis and progress to date cannot be considered part of the psychotherapy note.

Psychotherapy notes do not include any information about medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, or results of clinical tests; nor do they include summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes also do not include any information that is maintained in a patient’s medical record.

Reading this new Guidance is the easiest way for you to quickly review just what your responsibilities are under HIPAA and HITECH for maintaining patient privacy. Do take a look when you get a chance, and feel free to share your comments below. 

Smartphone Apps for Behavioral Health: Are you connected?

I read a newsletter yesterday that got me thinking. Mercom Market Intelligence Report on Healthcare IT for January 27, 2014 talked about the boom in patient at-home monitoring. I wondered what kind of apps might be around for behavioral health and whether they might be useful as supports in therapy.

When I worked as a psychologist, I practiced Cognitive Behavioral Therapy (CBT), as taught by Aaron Beck and his colleagues. The biggest struggle my patients had was to remember to do their homework, self-monitoring that almost always involved daily recording of activities, thoughts and reactions. I always provided them with a pocket-sized notebook to record things (this was 20 years ago, after all). Now, I would be more likely to find a higher tech way to assist them.

And so I began my quick review. I started with a Google search for ‘behavioral health self monitoring apps.’ I was somewhat surprised at the pages of links and articles that appeared. This has clearly become a hot area. Some of the apps are aimed at young people and children; many are aimed at adults.

I have not reviewed any of these apps. I am going to give you lots of articles and links so you can explore for yourself.

There are some more formal articles and research reports on the subject.

The American Psychological Association is offering some continuing education on the subject.

And multiple organizations list smart phone apps among a variety of self-help resources.

I was surprised at the broad array of resources available. Certainly each clinician will need to review these and determine if there any that fit well with their practice and modalities and might be beneficial to their clients. Perhaps some of you have already done that.

Please share any smartphone apps you use in your practice or organization to facilitate therapy progress. We would love to know what you have found useful.

Information Explosion

Do you ever feel like your head is going to explode from all the new pieces of information you are trying to cram into it?

‘No,’ you say. You never let yourself get overwhelmed by too much information – TMI. Please teach me how you do that!

I am constantly presented with new things that I think I should know more about, so I try to organize my life so I can learn it. Perhaps I spent too much of life as a student to let such a circumstance pass me by. If someone even vaguely implies that I should be informed about something, and they tell me where I can get the information, I feel compelled to go there and gain that knowledge. I have referred to myself as a sucker for learning something new. It is one of my greatest of joys; it is also one of my heaviest of burdens, especially as my aging brain resists assimilating more data.

The arena in which I am currently trying to become more informed is website analytics and email tracking. I know about Google Analytics. We have had an account for many years, since the days when it was fairly straightforward and simple. Have you looked at it lately?  This service has become so sophisticated that just clicking onto our Dashboard makes me feel like I need to start this only when my brain is at its sharpest.

For the last several years I have used an alternative service that has served up a lot of this analytic information in bite-sized portions for those like me with limited time to do it themselves. This has been a great tool, but that company has grown beyond my ability to keep up with their services. As a result, I am looking to bring some of that tracking and analysis in-house and share it with another staff person. We want to be able to use the tools that will help us and leave the rest behind….kind of a *KISS* approach.

So what is a person to do? Well, Google it, of course!

I started by doing this search: “google analytics learning” and found many places I can go for training. Of course, I will start with the Google Analytics Guide. Hopefully, this will get me started before I move on to ‘Get Started’ at the Google Analytics Training and Certification site. Or maybe I will start with Get Started….hmmm? But then, it seems that I need to learn something about this ‘regular expressions‘ stuff so I don’t get too lost. It looks like I can pay to teach me about this and everything else technical; or I can let Eugen Oprea at Udemy teach me for free. Or maybe it would be even better to go to this YouTube Google Analytics channel. Undoubtedly, this article from KISSmetrics, 50 Resources for Getting the Most Out of Google Analytics, will do it for me. After all, it is using that *KISS* notion, right?

You see what I mean about TMI? Maybe you have discovered a simpler way that does not include hiring a marketing firm. After all, we are in the behavioral health community and do not have lots of resources to spend on fancy stuff. How do you handle analytics for your website. Any insights for the likes of me?

Thanks for reading and for your comments.

ICD-10 Challenges Behavioral Health Providers

I have had a difficult time getting started with blogging this year. I have been struggling with finding a topic that I really wanted to address. So I have been actively avoiding the reminder in my calendar to ‘write blog’, sticking my head in the sand just a bit.

Trust our customers to come to the rescue.

I was told by both Seth and Trish that several customers have called this week with questions about what we are doing about the transition to the ICD-10. That is in spite of the fact that our last two newsletters have been filled with information about just that topic.

Synergistic Update | December 2013 is primarily about the ICD-10 transition, while in Synergistic Update | September 2013, the ICD-10 is our lead story. 

Perhaps I am not alone in my ostrich-like tendency!

What worries me most about the fact that some of our customers have not noticed these stories is that it is possible that the cash flow of provider organizations will be affected by this move to ICD-10 codes, at least initially. While the process of implementing the codes is not likely to be a very difficult thing for behavioral health organizations, it is definitely a huge matter for 3rd party payers of every stripe. You may need to be prepared with a short-term loan or line of credit in case your payers really bungle the transition!

So, please inform yourselves about this migration, how it will impact you, and what you need to do to get your organization ready for the change. You can view a webinar that was provided by the National Council in late January: Transitioning to ICD-10: Why It’s Important to Behavioral Health Providers and How to Prepare. You can attend (online or in person) CMS’ eHealth Summit on ICD-10 on February 14. Or, you can read the volumes of material provided by CMS at their website. Feel free to access some of the links in our newsletter stories as well as previous blog articles.

We may not always be successful, but we do make an effort to communicate early and often about matters that affect the practices of those we serve and their ability to obtain reimbursement for their services. Please take advantage of some of the many resources available to learn about and help you prepare for this transition. If you do not use our software, communicate with your own software vendor to learn about how this affects you. If you do use our software, read the articles in our newsletters so you will be ready when the transition begins!

Please feel free to share how you and your organization are preparing for the move to ICD-10.




A Model to Follow

Sometimes when I start looking for a topic for this blog, I struggle a bit. I find myself searching without finding a topic that feels useful and satisfying. When that happens, I go to newsletters I receive from a variety of sources to help me come up with ideas.

Today, I did not even go looking. A newsletter from one of our customers appeared, and I was reminded that some behavioral health organizations do this newsletter/blog/public information activity just right.

Southeast Psych of Charlotte, North Carolina sends me their newsletters regularly. They also send Southeast Psych’s Hotsheet, a summary of the videos and blogs and programs they have presented during the month. If you think your organization ought to be doing more public education and reaching out to your clients and to your community, you would be hard pressed to come up with a better model for doing so.

Take a look at some of their offerings and get an idea about how a behavioral health practice or agency can use the internet and social media to develop a significant influence in their community. Then get posting!

If your organization does something similar, please let me know so we can see many examples of how behavioral health providers can establish a community presence using electronic media.



CMS Notices on ICD-10 Transition Become More Concerned

The Centers for Medicare and Medicaid Services (CMS) has been sending out a newsletter on ICD-10 transition for over a year. The tone of that newsletter is beginning to change as we move into a countdown that is less than one year long.

What could possibly be the big deal? This is a question that many have asked, but until you assess your own practice or organization, you will not know. It is crucial that you begin to do this if you have not already done so. The impact in your organization may be minimal; on the other hand, it may be huge.

Here’s where to start. CMS has a large quantity of Provider Resources. This document is an Introduction to ICD-10: A Guide for Providers. Medscape has provided A Roadmap for Small Clinical Practices as well as a Small Practice Guide to a Smooth Transition. Both of these are continuing education programs aimed at small practices across many specialties.

If these resources do not appeal to you, or you think there is nothing for you to be concerned about in this transition, think about what happened earlier this year when we transitioned to a few new ICD codes that included compound codes for the first time for many types of providers. Did you experience an interruption in your cash flow? Now think about all the payers with whom you deal. How many of them will be completely ready to receive your claims with the new codes? How will you know whether to use the old or new codes? Can you count on your clearinghouse? your software vendor?

My take on this transition is that you must count on yourself. You must be prepared. No one else can do this for you. If you have not yet begun, now is the time to start.

Please share what your organization has done to begin the process of transition to the ICD-10.

Two Quick Notes: On Parity and HIPAA for Business Associates


On November 8, the Administration announced a final rule on Parity of mental health and substance abuse benefits with physical health benefits. The Departments of Health and Human Services along with Labor and the Treasury issued this final rule that

…implements the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, and ensures that health plans features like co-pays, deductibles and visit limits are generally not more restrictive for mental health/substance abuse disorders benefits than they are for medical/surgical benefits.

While health insurers have claimed to be supportive of Parity, their implementation in the absence of a Final Rule has been spotty and challenged by providers. We will now get to see what changes, if any, emerge.

HIPAA for Business Associates

You are a behavioral health provider, right? You have Business Associates, right? You even have Business Associate Agreements with those Business Associates, right? But do your Business Associates really have any idea what HIPAA is all about and what responsibilities and liabilities they have under the law?

You can make sure they have at least been exposed to some information in order to protect yourself, your patients, and their protected health information (PHI) a bit better. Send them the link to this free webinar happening on Tuesday, November 19 and ask them to attend. ID Experts is a fine provider of education and consultation and tools focused on privacy and security. HIPAA Compliance for Business Associates: Ignorance is Not Bliss should be a very instructive event, especially for Business Associates who really do not know their responsibilities.


Please share any information you have obtained about the Parity Final Rule or about training for Business Associates. We would love to be sure this information is well-circulated.


Do You Own Your Patient Records?

I just re-read an email newsletter by Monica Oss of Open Minds asking the question: “Who Owns Patient Records?“. The answer to this question varies from state to state, with some locales not having clear statutory requirements. In Florida, the provider owns the record but must provide a copy of it if the patient requests it. In fact, the HIPAA privacy standards make it very clear that the provider is responsible for sharing records with a patient (making copies) if a patient so requests. One of the major exceptions to this requirement is psychotherapy notes, which the behavioral health provider is not responsible to share with the patient and must not share with anyone else (like an insurance company) without the patient’s specific permission.

This matter is complicated when a provider uses an Electronic Medical Record (EMR) that is hosted by a software company. Why should that matter, you ask. Well, in the case of the hosted product, the software resides on the company’s servers, not on the provider’s computer. The provider pays to use the software; they don’t own anything. Unless the provider prints everything out, they do not really have possession of a record; the software company does.

What happens when they decide to go to another software program? The first company may be willing to provide them with reports and printouts of their records, but getting that into a new program can be a challenge. And if the old company is willing to work with the new one to transfer the data, the process can be very time-consuming and costly…and some companies won’t even do it.

And if the EMR is free, the provider may be agreeing to share some of the data they enter so the software company can sell it to other companies…all within the confines of their role as a Business Associate, of course. You do have a BAA with the software company, right? And of course, you have a good contract that you have read and understood before you signed it, right?

Hmmm…..this ownership question is complicated.

Please share your comments below.