Wes Williams, Ph.D., VP and CIO, Mental Health Center of Denver
Technology holds a lot of promise for improving health care, but without attention to change management and clinical workflow, staff may refuse to adopt the new technology. Health care payment reform —such as the Accountable Care Collaborative 2.0 that changes how Colorado’s Medicaid payments are distributed—emphasizes greater care coordination, which will hopefully lead to better care and a healthier population. Providers in Colorado are looking toward health information exchange for facilitating better coordinated care.
Colorado has two successful health information exchanges (HIEs): the Quality Health Network on the Western Slope, and CORHIO in the Front Range. Not all Coloradans, however, benefit from their health data flowing through these HIEs to help coordinate their treatment. In Denver, for example, where I am Chief Information Officer at the Mental Health Center of Denver, we cannot yet use CORHIO to exchange health information with our largest partner for primary care services. The Mental Health Center of Denver is a community mental health center providing lifespan clinical services by focusing on strengths and well-being. Denver Health, the nation’s largest federally qualified health clinic, provides primary care services to many of the patients receiving behavioral health services at the Mental Health Center of Denver. The Mental Health Center of Denver joined CORHIO years ago, but because of 42 CFR Part 2, the federal privacy law enacted to lower barriers to entering treatment for substance use disorders, has only been able to receive data from the HIE, not send any through it. Moreover, Denver Health is yet to join CORHIO.
Looking for alternatives to CORHIO for exchanging health information about our shared patients, Mental Health Center of Denver and Denver Health staff partnered with our electronic health record (EHR) vendors, Netsmart Technologies and Epic.
Both EHR vendors have been active in the development of Carequality, a framework for exchanging health information by directly querying other providers. Netsmart, the Mental Health Center of Denver’s EHR vendor, had designed an elegant, “Part 2”- compliant solution in which records would only be exchanged if the patient had consented to share the information with the querying provider. The Carequality implementation between Denver Health and the Mental Health Center of Denver was the first in the nation to use Carequality to exchange records covered by Part 2 rules. In the first six months, over 3500 records were sent from the Mental Health Center of Denver to Denver Health.
Determining out how to transmit the data between electronic health records was only the beginning of the implementation effort; clinical workflow needs also had to be addressed. When the Mental Health Center of Denver uses Carequality to query Denver Health about a patient, a C-CDA file is sent from Epic to Netsmart. A provider at the Mental Health Center of Denver next needs to review the information with the patient and decide what information, if any, should be imported into the Netsmart EHR. This process is called clinical reconciliation. Clinical reconciliation is one reason health information exchange can lead to better care coordination and clinical outcomes: by knowing what medications other doctors have prescribed, our psychiatrists can avoid prescribing medications that might have interactions with medications prescribed by the primary care physician.
Clinical reconciliation is one reason health information exchange can lead to better care coordination and clinical outcomes
One initial obstacle we encountered was that Epic sent a patient’s entire medication history with each query; Netsmart’s original clinical reconciliation workflow had been designed with the assumption that providers would send over just medications from a single visit, resulting in a very cumbersome reconciliation process. Mental Health Center of Denver staff worked with Netsmart to design a much more streamlined process in which staff only needed to click on the medications they intended to import, rather than clicking yes/no for every single medication in a patient’s history. Even with an easy interface, however, there was continued resistance to adopting the new technology.
The resistance was no longer the about software, but rather that technology had enabled a process that providers previously had not been able to perform, and therefore had not previously spent any time performing. Where would the extra time come from? Mental Health Center of Denver senior leadership convened with leadership from Netsmart to develop a change management strategy for adopting the new technology. To secure buy-in, we would first present the new clinical reconciliation process to our standards-of-care committee. Next, clinical champions would pilot the new workflow; other psychiatrists, rather than IT staff, would drive adoption.
Technology is a tool that can address many challenges, such as better care coordination in health care. The work of a CIO doesn’t stop with just delivering software. In this example, collaboration with our EHR vendor yielded elegant technology solution, and the partnership extended to the change management work that was necessary to adjust how psychiatrists spent time with patients to enable higher-quality care.