Chronic Mental Health: Improving Outcomes through Ambulatory Care Coordination (Nebraska)

Project Final Report (PDF, 292.64 KB) Disclaimer

Project Details - Ended

Summary:

Without electronic communication, behavioral health providers cannot follow the full treatment path of their patients who have mental health issues as they move between various providers in urban and rural outpatient settings, mental health hospitals, protective custody, and crisis mental health facilities. This project demonstrated how health information exchange (HIE) between rural and urban providers improves ambulatory patient care coordination and safety across treatment settings. It developed and implemented the Electronic Behavioral Health Information Network (eBHIN), a regional HIE in southwest Nebraska, to decrease the time and effort it takes for providers to access comprehensive and accurate information about their patients.

The specific aims of this project were to:

  • Identify provider barriers to technology acceptance. 
  • Implement an HIE among three major behavioral health provider facilities. 
  • Collect data on how timely access to accurate information relates to quality of care. 

eBHIN was implemented in the 16-county region of southeast Nebraska that comprises the Region V Behavioral Health Authority, and throughout the five counties of Region VI. These two regions are home to approximately 60 percent of Nebraska’s total population. Thirty organizations currently participate in eBHIN, with 77 percent of consumers having “opted-in” to share their health information.

The project used interviews and surveys to study two subject areas: 1) provider barriers and benefits to technology acceptance in the behavioral health setting; and 2) behavioral health care technology acceptance and adoption.

Among the barriers cited during interviews, all providers mentioned privacy and security concerns; nearly all providers mentioned delivery-of-services barriers; and more than half the providers cited quality-of-care barriers. For benefits, all providers mentioned quality-of-care benefits; two-thirds discussed delivery-of-services benefits; and fewer than one-in-ten discussed privacy and security benefits.

Thirty-three percent of respondents had negative beliefs of HIE, including a strong belief that HIE would add cost and time burdens. In addition, this group believed that the HIE would present access and vulnerability issues, would negatively impact workflow and control, and were skeptical that technology would improve care and communication. Sixty-seven percent of respondents had positive beliefs about HIE, including the belief that HIE would improve care and communication, and a belief that HIE would positively impact workflow and control. This group did not believe that the HIE would add cost and time burdens. Those who felt positively about HIE were younger, more confident about their computer skills, and had prior positive experience with electronic health records. Overall, the project found that behavioral health providers have positive attitudes toward sharing information electronically, but have concerns about privacy and cost.

Chronic Mental Health: Improving Outcomes Through Ambulatory Care Coordination - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017838
  • Project Period: 
    September 2008 – September 2013
  • AHRQ Funding Amount: 
    $1,199,871
  • PDF Version: 
    (PDF, 293.42 KB)

Summary: Without electronic communication, behavioral health providers cannot follow the full treatment path of patients with mental health issues as they move between various providers in urban and  rural outpatient settings, mental health hospitals, protective custody, and crisis mental health facilities. This project explores how the exchange of health information between rural and urban providers in the behavioral health field can improve ambulatory patient care coordination and safety across treatment settings. Specifically, the project examines provider barriers to technology acceptance in the behavioral health setting, behavioral health care technology acceptance and adoption, and the effects of a health information exchange (HIE) on clinical outcomes.

The development and implementation of a regional behavioral HIE in southeast Nebraska was based on the premise that the HIE would decrease the time it takes for providers to access comprehensive and accurate information, thus creating better access to patient information between and among the provider care team serving an individual with mental illness. This, in turn, would improve continuity of care by providing an electronic link between Nebraska’s multiple service settings. The ultimate end for the project would be that through the provision of basic electronic information to coordinate patient care between behavioral health providers, rural hospitals, and the emergency behavioral health system will improve the long-term health outcomes of individuals with serious, persistent mental illness.

During the first phase of the project, the Electronic Behavioral Health Information Network (eBHIN) team issued a request for proposals, researched vendor qualifications, and ultimately selected products from NextGen Healthcare. At the same time, the research team began to design the HIE and conducted a behavioral health provider survey focused on technology acceptance. In the second phase of the project, the team developed the HIE infrastructure, equipped provider offices with new or updated technology, and provided training to participating providers. In the ongoing phase three, the team is implementing the HIE in organizations in Region 5 of Nebraska. Data will be collected to evaluate how timely access to accurate information might improve the quality of care for those experiencing a behavioral health crisis and who have an immediate need for entrance into the emergency behavioral health care system.

Specific Aims:

  • Identify provider barriers to technology acceptance. (Ongoing)
  • Implement an HIE among three major behavioral health provider facilities. (Ongoing)
  • Collect data on how timely access to accurate information relates to quality of care. (Upcoming)

2012 Activities: At the end of 2012, the HIE was live in all of Region 5 with the exception of one health system organization where Ms. Baker and her team are still finalizing the terms of the interagency agreement. Deployment was underway in organizations in Regions 1 and 6; while a readiness assessment of Regions 2, 3, and 4 was completed during the year. By the end of December, there were more than 25,000 behavioral records in the system.

During the year, the project team had some issues with the recruitment of providers for the second and third studies, so they made minor protocol changes that resulted in an increase of their recruitment numbers for the survey of acceptance and use, and interviews with high and low users. By the end of 2012, they had recruited 62 providers who completed a 100-question survey assessing the HIE’s ease of use, usefulness, quality of information, timeliness, and accuracy of data. Interviews with high and low users of the system were ongoing at the end of the year. In addition, the project team started reviewing the data on the HIE system usage, and plan to assess logon trends, minutes in the system, and which aspects of the system providers use.

Other research activities focused on manuscript development, including the dissemination of findings from a statewide survey focused on benefits and barriers to electronic sharing of client information that was sent to all practicing behavioral health providers in Nebraska. An article summarizing these findings, Behavioral health providers’ beliefs about health information exchange: a statewide survey, was published in the July-August volume of the Journal of the American Medical Informatics Association. An article, Electronic health records: eliciting behavioral health providers’ beliefs, presenting findings from interviews with 32 behavioral health providers about their beliefs about HIE and electronic health records (EHRs) was published in the Community Mental Health Journal.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track, and project budget spending is roughly on target. Due to initial project delays in 2009 and the unanticipated amount of time to develop some specifications for the HIE, the team is using the second of two no-cost extensions to ensure adequate time to complete the remaining studies and the subsequent analysis and manuscript preparation.

Preliminary Impact and Findings: Analysis of the statewide survey showed that a majority (67 percent) of providers were positive about the impact of HIE. Most behavioral health providers are supportive of HIE; however, adoption and use may continue to lag behind that of medical providers due to perceived cost and time burdens, and concerns about access to and vulnerability of information.

Themes identified through interviews with behavioral health providers included quality of care, privacy and security, and delivery of services. All providers believed there are benefits to quality of care when using EHRs, while 59 percent of providers noted barriers to their use. Eighty-one percent of providers expressed overall support for electronic behavioral health records.

Target Population: Adults, Chronic Care*, Mental Health/Depression

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Chronic Mental Health: Improving Outcomes through Ambulatory Care Coordination - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017838
  • Project Period: 
    September 2008 - September 2012
  • AHRQ Funding Amount: 
    $1,199,871
  • PDF Version: 
    (PDF, 215.48 KB)

Summary: Without electronic communication, behavioral health providers cannot follow the full treatment path of patients with mental health issues as they move between various providers in urban and rural outpatient settings, mental health hospitals, protective custody, and crisis mental health facilities. This project explores how the exchange of health information between rural and urban providers in the behavioral health field can improve ambulatory patient care coordination and safety across treatment settings. Specifically, the project examines provider barriers to technology acceptance in the behavioral health setting, behavioral health care technology acceptance and adoption, and the effects of a health information exchange (HIE) on clinical outcomes.

The development and implementation of a regional HIE in southeast Nebraska will decrease the time it takes for providers to access comprehensive and accurate information, thus creating better access to patient information between and among the provider care team serving an individual with mental illness. This, in turn, will improve continuity of care by providing an electronic link between the multiple service settings that serve Nebraska residents. The provision of basic electronic information to coordinate patient care between behavioral health providers, rural hospitals, and the emergency behavioral health system will improve the long-term health outcomes of individuals with serious, persistent mental illness.

During the first phase of the project, the Electronic Behavioral Health Information Network (eBHIN) team issued a request for proposals, researched vendor qualifications, and ultimately selected products from NextGen Healthcare. At the same time, the research team began to design the HIE and conducted a behavioral health provider survey focused on technology acceptance. In the second phase of the project, the team developed the HIE infrastructure, equipped provider offices with new or updated technology, and provided training to participating providers. In phase three, the team will implement the HIE in 11 organizations at 15 practice settings. Once the environment is established, data will be collected to evaluate how timely access to accurate information might improve the quality of care for those experiencing a behavioral health crisis and who have an immediate need for entrance into the emergency behavioral health care system.

Specific Aims:

  • Identify provider barriers to technology acceptance. (Ongoing)
  • Implement an HIE among three major behavioral health provider facilities. (Ongoing)
  • Collect data on how timely access to accurate information relates to quality of care. (Upcoming)

2011 Activities: System design activities focused on technical and procedural infrastructure development, security compliance, system implementation, and training. Development of the HIE customization from NextGen continued into 2012; however, the study team has been deploying other parts of the system in the interim so that providers will have records to share once the HIE is implemented. The team worked closely with Magellan Community Health and the Nebraska Administrative Services Organization to develop a file transfer process based on clear technical requirements. They also successfully completed a data center security audit. No high vulnerabilities were found. Three medium vulnerabilities were found and addressed immediately. Low vulnerability areas will be addressed through policies and procedures. The team is developing specifications and procedures for secure direct messaging between the NextGen system and the HIE application. By the end of July 2011, the system was live for data entry and data upload at 15 practice sites, including data entry of the shared record, data aggregation, and upload to Magellan. By the end of December 2011, there were 10,000 records in the system. In addition to significant site training efforts, Dr. Baker and her team worked closely on connecting sites to the data center and providing training on the upload process.

Research activities focused on manuscript development, including the dissemination of findings from a statewide survey focused on benefits and barriers to electronic sharing of client information that was sent to all practicing behavioral health providers in Nebraska. An article summarizing these findings was accepted for publication by the Journal of the American Medical Informatics Association. An article, Electronic health records: eliciting behavioral health providers' beliefs, presenting findings from interviews with 32 behavioral health providers regarding their beliefs about HIE was published in the Community Mental Health Journal. The research team is also preparing to begin two implementation studies that will include surveys of end-users, using the technology adoption model to explore intentionto- use, and looking at actual usage patterns.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track. The project budget funds are significantly underspent, as the project team is reserving funds for the impact study. Due to initial project delays in 2009 and the unanticipated amount of time to develop some specifications in 2010, the team is using a 1-year no-cost extension to ensure adequate time for the impact study and subsequent analysis and manuscript preparation.

Preliminary Impact and Findings: Analysis of the statewide survey showed that a majority (67 percent) of providers were positive about the impact of HIE, while the remainder (33 percent) were negative. Most behavioral health providers are supportive of HIE; however, adoption and use may continue to lag behind that of medical providers due to perceived cost and time burdens and concerns about access to and vulnerability of information.

Themes identified through interviews with behavioral health providers included quality of care, privacy and security, and delivery of services. Benefits to quality of care were mentioned by 100 percent of the providers; barriers by 59 percent of providers. Barriers involving privacy and security concerns were mentioned by 100 percent of providers; benefits by 22 percent. Barriers to delivery of services were mentioned by 97 percent of providers; benefits by 66 percent. Eighty-one percent of providers expressed overall positive support for electronic behavioral health records.

Target Population: Adults, Chronic Care*, Mental Health/Depression

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Chronic Mental Health: Improving Outcomes through Ambulatory Care Coordination - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017838
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,199,871
  • PDF Version: 
    (PDF, 376.23 KB)


Target Population: Adults, Chronic Care*, Mental Health/Depression

Summary: Providing care for people with mental health illness poses unique and difficult challenges. Without electronic communication, behavioral health providers cannot follow the full treatment path of patients as they move among various providers in urban and rural outpatient settings, mental health hospitals, protective custody, and crisis mental health facilities. This project explores how the exchange of health information between rural and urban providers in the behavioral health field can improve ambulatory patient care coordination and safety across treatment settings. Specifically, the project examines provider barriers to technology acceptance in the behavioral health setting, behavioral health care technology acceptance and adoption, and the effects of health information exchange (HIE) on clinical outcomes.

The development and implementation of a regional HIE in southeast Nebraska will decrease the time it takes for providers to access comprehensive and accurate information, thus creating better access to patient information between and among the provider care team serving an individual with mental illness. This, in turn, will improve continuity of care by providing an electronic link between the multiple service settings that serve Nebraska residents. The provision of basic electronic information to coordinate patient care between behavioral health providers, rural hospitals, and the emergency behavioral health system, will improve the long-term health outcomes of individuals with serious, persistent mental illness.

During the first phase of the project, a committee issued a request for proposals, researched vendor qualifications, and ultimately selected products from NextGen Healthcare, certified by the Certification Commission for Health Information Technology. At the same time, the team began to design the HIE and also conducted a behavioral health provider survey focused on technology acceptance. In the second phase of the project, currently underway, the team will develop the HIE infrastructure, equip provider offices with new or updated technology, and provide training to participating providers. In phase three, the team will implement the HIE in three provider facilities. Once the environment is established, data will be collected to evaluate how timely access to accurate information might improve the quality of care for those experiencing a behavioral health crisis and who have an immediate need for entrance into the emergency behavioral health care system.

Specific Aims:
  • Identify provider barriers to technology acceptance. (Ongoing)
  • Implement an HIE among three major behavioral health provider facilities. (Ongoing)
  • Collect data on how timely access to accurate information relates to quality of care. (Upcoming)

2010 Activities: System design activities continued to focus on organizational development of the Southeast Nebraska Behavioral Health Information Network’s Regional Health Information Organization and on system implementation. The State's Operational Plan for statewide HIE was approved by the Office of the National Coordinator for Health Information Technology. Early in the year, the electronic Behavioral Information Network (eBHIN) encountered system design challenges as well as problems in recruiting appropriate project management personnel, delaying system implementation by 6 months. However, a new project manager, working with an information technology consultant and NextGen, has been able to adapt the project plan and a new “Go-live” date has been established for June 2011.

In collaboration with the University of Nebraska, Dr. Baker sponsored an “HIE Kick-Off Celebration.” The President of NextGen Healthcare Information Systems joined a group of approximately 100 stakeholders for a presentation highlighting system capabilities and outlining plans for implementation. A data center hosting timeline was developed to facilitate a production environment available in preparation for go-live. An HIE implementation team has been established representing all of the organizations that will be participating in the network. The project manager has been working with this team and NextGen on finalizing the record design and functionality. The referral management and waitlist management functionality has been defined.

Working with a core group of providers identified “super users,” the application has been built with provider-specific information. The eBHIN team continues to work with NextGen and the Magellan Behavioral Healthcare system to design the file transfer protocol for the upload of registration and authorization information to the State of Nebraska. The file transfer structure has been designed and preliminary testing has begun.

Research activities focused on dissemination, data collection, data analysis, and interpretation of a statewide survey, and on completing analysis and interpretation on a provider survey conducted in 2009. The statewide survey focused on the benefits and barriers to electronic sharing of client information. This survey was sent to all practicing behavioral health providers in Nebraska. A total of 2,010 surveys were sent out with 667 respondents. The grant team was pleased with the response rate given the population. Highlights of these findings were presented at the HIE Kick-Off Celebration. A manuscript is being developed to disseminate the findings from the statewide survey. A manuscript summarizing findings from the 2009 provider survey has been published.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project was significantly underspent during this calendar year due to pending acquisition of the Data Center equipment, but project progress is close to schedule with some deviations. Dr. Baker is now moving ahead at a very rapid pace. A go-live date has been set for March 2011, a Data Center hosting timeline is in place, and the application has been built with provider-specific information.

Preliminary Impact and Findings: Most providers reported feeling positively disposed to adopting electronic health records. Many expressed the belief that the decisionmaking about electronic health records is different in behavioral health than other sectors of the medical community. For instance, most providers believed that information in behavioral health records is more sensitive and the client more vulnerable. Also, some were concerned that the subjectivity of behavioral health information can make electronic sharing a complicated process. Benefits and barriers to technology acceptance, as articulated by providers, were grouped into six theme areas: security and privacy; delivery of behavioral health care; quality of care; adoption and implementation; financial impacts; and business operations.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Chronic Mental Health: Improving Outcomes through Ambulatory Care Coordination - Final Report

Citation:
Baker W. Chronic Mental Health: Improving Outcomes through Ambulatory Care Coordination - Final Report. (Prepared by Electronic Behavioral Health Information Network under Grant No. R18 HS017838). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 292.64 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Population: 
Medical Condition: 
This project does not have any related resource.

Sharing Electronic Behavior Health Records: A Nebraska Perspective

This is a questionnaire designed to be completed by physicians, implementers, and nurses across a health care system setting. The tool includes questions to assess benefit, the current state, usability, perception, and attitudes of users electronic health records and health information exchange.

Year of Survey: 
Created prior to 2011
Survey Link: 
Sharing Electronic Behavior Health Records: A Nebraska Perspective (PDF, 128.09 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Document Type: 
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
This project does not have any related project spotlight.
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.