Preparing for a new era: EHR standards for behavioral healthcare

We have moved into an era wherein widespread adoption of electronic health record (EHR) systems has become a national priority. President Bush recently underscored their importance to the nation's healthcare system in his 2006 State of the Union address. Department of Health and Human Services (HHS) Secretary Mike Leavitt declared EHRs to be among his three top priorities when he launched the American Health Information Community in June 2005.1

The Institute of Medicine (IOM) has defined EHRs as encompassing:

• the longitudinal collection of electronic information pertaining to an individual's health and healthcare;

• immediate electronic access—by authorized users only—to person- and population-level information;

• provision of knowledge and decision support to enhance the quality, safety, and efficiency of patient care; and

• support for efficient processors of healthcare delivery.2

The importance of EHR systems to patient safety and quality of care has been well established.3 Nevertheless, the rate of adoption has been slow. The obstacles most often cited are cost-related factors, risk aversion, and insufficient knowledge of how to manage a successful implementation. Underlying and contributing to these obstacles are a lack of nationwide standards for the collection, coding, classification, and exchange of clinical and administrative data.4 It is a daunting task to address all these challenges and promote widespread adoption of EHR systems. To intensify and coordinate efforts to accomplish this nationally, President Bush established the Office of the National Coordinator for Health Information Technology in 2004 and appointed David Brailer, MD, PhD, as its leader.

Summit Recommendations

The behavioral healthcare field has specific interests and concerns pertaining to EHRs that probably would not be addressed without an organized effort. In 2005, the Software and Technology Vendors’ Association (SATVA) and SAMHSA worked together to organize and cohost the National Summit on Defining a Strategy for Behavioral Health Information Management and Its Role Within the Nationwide Health Information Infrastructure. More than 140 behavioral healthcare leaders were invited from a comprehensive range of stakeholder groups to meet in Washington, D.C., on September 29 and 30 to begin laying the foundation for a nationwide information infrastructure for behavioral healthcare services. (You can access the complete set of Summit presentations and workgroup summaries in clear audio recordings with, if applicable, synchronized slide presentations at www.mhsip.org/itsummit/index.htm.)

Summit participants concluded that the behavioral healthcare field should set development of EHR standards as a top priority. They recommended the following:

• Behavioral healthcare perspectives should be represented within general healthcare standards development organizations and within all EHR and regional health information network programs initiated through HHS and its agencies.

• A public-private and broadly representative behavioral health group should be formed that can coordinate and harmonize data standard work pertaining to behavioral healthcare, as well as coordinate incentive strategies for widespread EHR adoption.

• Basic clinical specifications for a behavioral health EHR should be defined and serve as the core of a broader set of behavioral health-specific software certification standards.

IOM Recommendations

A month after the Summit, on November 1, the National Academy of Sciences released the first IOM report to comprehensively review and address issues in the behavioral healthcare field. In Improving the Quality of Health Care for Mental and Substance-Use Conditions, an entire chapter was devoted to information management issues. Among the recommendations were the following:

• HHS should create and support a continuing mechanism to engage mental and substance use (M/SU) healthcare stakeholders in the public and private sectors in developing consensus-based recommendations for the data elements, standards, and processes needed to address unique aspects of information management related to M/SU healthcare. The recommendations should be provided to the appropriate standard-setting entities and initiatives working with the Office of the National Coordinator for Health Information Technology.

• Public- and private-sector persons and organizational leaders in M/SU healthcare should become involved in, and provide for staff involvement in, major national committees and initiatives involved in setting healthcare data and information technology standards to ensure that the unique needs of M/SU healthcare are designed into these initiatives at their earliest stages.

Establishing EHR Standards Through HL7

Health Level Seven (HL7) is a healthcare informatics standards development organization accredited by the American National Standards Institute and by the International Organization for Standardization. In early 2004, HL7 released a draft of proposed EHR standards. Recently, the Certification Commission for Healthcare Information Technology (CCHIT) used those standards to propose an approach for certifying EHR software, thereby heightening the stakes for EHR standards dramatically. CCHIT did not involve the behavioral healthcare field in its initial development of EHR criteria for ambulatory care settings, and consequently modifications are needed so the criteria can be applied meaningfully to our field's specific interests and concerns.

In December 2005, HL7 held a balloting process on more than 700 criteria for EHR functions within its 2004 proposed draft standards. SATVA and SAMHSA responded quickly. We each joined HL7 and worked intensively together through December on the ballot, participating in more than 20 hours of conference calls. We first oriented to HL7 terminologies and procedures with the help of a consultant expert, and then reviewed each of several hundred criteria with inclusion of other stakeholders through the Behavioral Health Standards Workgroup. We reached consensus on all our voting decisions, and for criteria we voted to change we virtually agreed to new wording and written rationales. As required, SATVA and SAMHSA each submitted separate ballots, but our votes were the same so as to present a strong and unified voice.

In January 2006, SATVA and SAMHSA representatives participated in the HL7 tri-annual Working Group Meeting in Phoenix. This weeklong meeting was exactly what its name implies—a series of working group meetings from morning through evening to develop informatics standards. It is beyond the scope of this article to summarize all the types of standards development efforts ongoing within HL7. Our behavioral health contingent focused almost exclusively on the EHR standards, which required reconciliation of the original draft standards with more than 3,000 lines of comments and ballot votes from HL7 members worldwide. We progressed through approximately 20% of the work during that week, and then participated in several weekly conference calls throughout January and February to complete the task. The plan is to bring the revised ballot of standards to another vote soon, and begin a final reconciliation process shortly thereafter at an HL7 Working Group Meeting with follow-up conference calls.

Those of us participating on behalf of the behavioral healthcare field want to ensure that our recommendations are incorporated into the finalized standards so they are sensitive to behavioral healthcare interests and concerns. However, our work won't stop there. The standards currently under development constitute an all-inclusive “superset,” not all of which will apply to any one organization or specialty area. The subsequent steps will be for specialties such as behavioral health to establish our own HL7 Special Interest Groups and build Conformance Profiles applicable to our own specialty areas and types of settings. We will accomplish this by incorporating applicable criteria from the superset and adding new criteria if needed according to HL7 procedures. Once our Conformance Profile work is completed, CCHIT may use it to define what functions must be present in a software product for it to be certified as an EHR system for behavioral healthcare settings. Stay tuned for future articles on this work and information on how you can become involved.

To be successful at this HL7 standards development effort requires an intensive time investment, but the experience is both interesting and professionally rewarding. HL7 participants come from all over the world and are well-informed, hardworking, and welcoming. The work of standards development for behavioral healthcare requires integrative thinking that draws from knowledge of technology, clinical processes in varied settings, and political issues and trends pertaining to behavioral healthcare. The eventual impact of this work on behavioral health consumers, providers, services, and software will be profound.

References

1. U.S. Department of Health and Human Services. American Health Information Community. Available at: www.hhs.gov/healthit/ahic.html.
2. Institute of Medicine. Key Capabilities of an Electronic Health Record System. Washington, D.C.: National Academies Press, 2003. Available at: www.nap.edu/catalog/10781.html.
3. Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: Achieving a New Standard for Care. Washington, D.C.: National Academies Press, 2004. Available at: https://fermat.nap.edu/catalog/10863.html.
4. Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, D.C.: National Academies Press, 2005. Available at: www.nap.edu/catalog/11470.html.