Testimony Before the Institute of Medicine Committee

Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders
September 14, 2004

Prepared by the Software and Technology Vendor’s Association (SATVA)
Presented by John A. Paton, Chair of SATVA, and Chairman of CMHC Systems, Inc.

I represent The Software and Technology Vendors Association, SATVA, which is the sole trade association for technology vendors in the behavioral healthcare market space. Behavioral health in our context encompasses mental health, substance abuse, corrections, juvenile justice, and other social services. SATVA members produce, sell, implement and support software products used to provide and manage behavioral care for the commercial and public sector in all fifty states, DC, and the territories. SATVA was formed 3 years ago with the mission to benefit the behavioral healthcare industry through improved cooperation between vendors, improved quality of products and services, and the establishment of standards. There are presently 20 member organizations whose technology solutions include all the components of Health Information Technology (HIT) outlined in the IOM report of 1999, although our customers’ focus is often primarily on the business application of our products, rather than the clinical side of the service delivery system. Our testimony will identify areas for potential improvements and offer short term and long term recommendations.

The complexity of billing, reimbursement, and regulatory reporting is extensive in behavioral health, and because of the critical need to implement and maintain such systems, technology for clinical information and decision support has received disproportionately less focus by providers. In behavioral health we estimate that the cost of billing, financial reimbursement, and regulatory reporting is approximately 10% of the industry’s total expenditure, or about $12 billion. If this amount could be reduced and a portion redirected to improving clinical processes and related information technology, the quality of clinical care to consumers could be greatly improved, and the vision of the IOM could be realized more quickly. Behavioral health agencies spend proportionately less on technology than their medical-surgical counterparts. We estimate that less than 1% of behavioral health budgets, less than $1.2 billion, is spent on information technology while medical healthcare spends 3-4%, or about $60 billion. We firmly believe that the failure of the behavioral health market to increase its commitment to HIT has affected the quantity and quality of services to consumers. This deficit must be addressed.

In most behavioral health settings, attempts to use existing medical-surgical information systems have not been successful. Although the scope of this testimony cannot address all the complex issues, two of the primary reasons are especially significant:

  1. Although some behavioral healthcare follows a medical model, many of the services provided extend beyond medical care into social, vocational, residential and supportive services. Medical information systems assume that a clinician, usually an MD or nurse, is providing specific, procedure code-based services to the consumer. In contrast, behavioral health systems must take into account that services may be also provided by a non-traditional provider, in a non-traditional setting, and may even have non-traditional reimbursement. This leads to the second point;
  2. Behavioral healthcare has inordinately complex billing, financial reimbursement and regulatory reporting requirements. Oversight and funding of behavioral health services is much broader and more varied than what is covered by the Center for Medicare and Medicaid Services and insurance systems, and includes states, local governments and private agencies. Therefore, efforts to simplify matters must satisfy a greater number of stakeholders.
There are many barriers to expanded use of technology, but we believe the most significant are:

  1. Lack of a single, universal standard for encounter reporting – this is made worse by the fact that many states and local governmental entities, lacking other necessary reporting infrastructure, have used the HIPAA structure as a vehicle to accomplish non-claims related reporting.
  2. Lack of funds for technology infrastructure development – Lower traditional reimbursements for behavioral health services have resulted in lower salaries for staff, including technology staff. This in turn correlates to high turnover rates, increased burden of training, and decreased productivity.
  3. Highly complex security and privacy requirements – Most every state and territory has some specific regulation about the protection of clients’ mental health data and most have even more stringent requirements for substance abuse related information. In fact, in some states, substance abuse and mental health are subject to completely different, and sometimes conflicting, regulations.

We applaud the IOM’s recognition of the vital role of HIT in improving quality of care, and we are also encouraged by the increasing governmental support for innovation in behavioral healthcare related technology. But only with oversight and concerted effort can we bring about the transformation required. Here are several of the most critical steps we believe necessary, along with a general timeline. We believe that these align with the strategic direction of the IOM and can be accomplished through the joint efforts of all stakeholders.

One-to-five years

  • Simplify reimbursement processes with the target that at least half of the $12 billion currently spent on billing, financial reimbursement and reporting can be redirected to fund critically needed technology infrastructure and innovation in behavioral healthcare.
  • Create a Center for Behavioral Health Technology Transformation that will further define the application of information science, and promote adaptation of behavioral healthcare services to healthcare technology. We believe this can be best accomplished as a public-private partnership, in the spirit of recommendations by the President’s Freedom Commission.
  • Standardize the datasets needed for a behavioral health EHR and especially those associated with assessments and outcomes reporting.
  • Expand clinical training programs to include the application of technology, and require certification of continuing technology skills and practices.
Five-to-ten years

  • Move away from episode-based reimbursement models towards case rates, population-based reimbursement rates, and capitation within payer-provider transactions.
  • Develop personal health and spending accounts to provide consumers access to and accountability for healthcare spending, and allow for more consumer participation in clinical decision-making.
  • Create a statistical database to support the use of evidence-based practices, encourage and provide measures for the fidelity of treatment, and provide evidence to support specific treatment protocols.
  • Develop a statistical model for behavioral health diagnostic decisions, treatment outcomes, and related treatment standards to enable a more person-centered clinical platform.
  • Develop a model in which behavioral health payers and providers operate through on-line dedicated high-speed Internet connections for improved coordination of relevant interactions.
Our vision for the period beyond ten years includes broad recommendations for the direction of healthcare related technology. This long term vision includes implementing a high-bandwidth secure network connecting all healthcare stakeholders, leveraging artificial intelligence in behavioral health treatment for clinical decision support, using new technologies for better decision integration to support quality of care, and developing better human-machine interfaces to improve quality, performance and availability of outcome information.

In order to cross the quality chasm with information technology, we strongly urge the IOM to recommend at least the following;

  1. Simplify reimbursement processes so that at least half of the $12 billion currently spent on billing, financial reimbursement and regulatory reporting can be redirected to fund critically needed technology infrastructure and innovation in behavioral healthcare. This is a rare example where funding for major improvement is built in to the current system.
  2. Develop a new institute to serve as the national Center for Behavioral Health Technology Transformation that will further define the application of information science, and promote adaptation of behavioral healthcare services to healthcare technology. The Center’s charge should include:
    1. Developing a ten-year strategic plan for behavioral health IT
    2. Developing standard datasets to support the EHR, and the IT infrastructure required to support those standards.
    3. Establishing a national behavioral healthcare technology fund to support acquisition of sufficient technology infrastructure in the behavioral health field and implementation of new clinical innovations and quality improvement.
SATVA is committed to improving the efficiency and efficacy of behavioral healthcare through information technology. In concert with CMHS, we have begun developing the framework of a strategic plan for technology innovation which we believe could be the starting point for the public/private partnership, the Center for Behavioral Health Technology Transformation. We look forward to also working with the IOM and other stakeholders in any way possible to realize the shared vision of improved clinical care through better use of technology.

Thank you.



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