computer hit in the 90s

Behavior's ProblemOverwhelmingly regulated by managed care, behavioralhealth providers still struggle for--andagainst--computerization

by Wendy J. Meyeroff and Richard E.Meyeroff

March 1999 - Healthcare Informatics

Treating mental health problems is complicated enoughwithout managed care issues, and with them, behavioralhealthcare becomes a field in desperate need of IT solutions.

Experts point out that behavioral healthcare by its very natureis vulnerable to patients who abuse the system. After all,when an orthopedist checks a broken leg he or she can tellwhether it has healed or not; it does the patient no good toinsist that the leg's still broken. It's much easier for patients tomanipulate ongoing care for depression, anxiety or otherproblems. For the same reason, it is also easier forpractitioners to misdiagnose and treat mental health problems.

The opportunities for abusing the system, misdiagnosis andmistreatment, say the experts, are why behavioral health isone of the areas most regimented by managed care. Accordingto Craig Muzilla, VP of marketing and business developmentfor Instream, an electronic commerce company in Burlington,Mass., "Eighty-five percent of behavioral health is undersome type of managed care. That's the highest percentage ofany healthcare business."

Such regimentation doesn't come cheaply. A study conducedby Towers Perrin, an international management consulting

Healthcare Informatics: Behavior's Problem

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firm in New York City, notes that managed care is 50 percentmore costly to administer than fee-for-service. Cost cuts wereachieved, says Tom Cayton, PhD, project director for ThePsychological Corp. in San Antonio, Texas, distributor oftraditional and electronic psychological tests, "by reducingaccess through establishing hurdles."

Those hurdles multiply horrifically in behavioral healthcare.Whereas a broken leg really only dictates one course oftreatment, the options are staggering when it comes to treatingsomething like depression. Does this patient need medication,group therapy, biofeedback, a combination--or something elseentirely?

Meeting individual needsThe number of behaviors one has to evaluate, code, track,etc., is staggering. Jim McGrody, VP of marketing for ThePsychological Corp. notes that the company's OPTAIOsystems evaluate about 1,600 different behaviors andproblems, derived from the American PsychiatricAssociation's DSM-IV list.

McGrody says equipment and software often are not the mainobstacles to provider use. (The OPTAIO programs, forexample, can run on Windows in a stand-alone format ornetworked via a wide area network.) Rather, ThePsychological Corp. has found that the biggest obstacle togetting providers to use computerized systems is that toooften those systems don't meet their demands. "The ITsystems are designed by IT guys...and too often the resultingsystem doesn't meet clinical needs." The result is theinfamous GIGO (Garbage In, Garbage Out) and providerswho are asking, "Why should I learn your new computersystem, or fill out some computerized form, if it's not going tohelp me help my patient?"

Heather Porter, director of marketing and communityoutreach at Elmcrest Behavioral Health Network in Portland,Conn., notes one of the ways they are avoiding this scenario."We've put together an MIS steering committee. It consistsnot just of MIS people, but also reps from accounting, casemanagement, admissions, purchasing and other departments."

The IT challengeConsider the paperwork involved in behavioral healthcare.Muzilla explains the nightmare: "You start, let's say, with areferral from the primary care doctor to the managed care



organization, which is then routed to a specialist in behavioralhealthcare. The new provider does an initial assessment andmay apply for a precertification from the managed careorganization to see the patient for one or two visits. Afterthese visits, the provider rolls out a formal treatment plan tothe managed care organization, which sends back treatmentauthorization for X number of visits. At the end of this cyclethere's a closing summary." All of that adds up to a lot offorms flowing back and forth.

That's assuming the provider doesn't feel treatment should beextended. If he or she does, there's more paperwork, morereviews and more communication between provider and casemanagers. (Case managers are another expense specific tobehavioral health; they tend to be licensed professionals suchas psychologists.) "Good healthcare is 90 percent informationexchange," according to Mark Gerner, CEO of WorkFlowDesigns, a consulting and training firm in Dallas, specializingin Web-based applications.

It's already easy to see why computerizing behavioralhealthcare gives IT managers nightmares, but Ken Hawes,executive VP/CIO of Magellan Behavioral Health, a specialtymanaged care organization, says that's the tip of the iceberg.He points out that there is a whole different set of challengesfrom IT's perspective. Among them: companies shorteningtime frames for implementation of new systems or systemchanges; accommodating special customer needs (likegenerating special reports); accommodating changes likeregulatory accreditation; handling confidentiality issues;juggling differences in benefit plans; and the general lack ofstandardization in healthcare.

Of course, claims and billing are undoubtedly major concernswith any new computer system. Magellan has not one, buttwo claims systems. The HMO work is handled byHewlett-Packard hardware on an AMISYS platform, whilethe employer union uses an IBM-driven AS/400 system. Thepublic sector uses either--depending on the complexity of thespecific claim it's processing.

But it's important, say the experts, to think beyond claims tothe total data the system can process. For example, one of themany benefits of Magellan's new clinical system is instanttransfer of authorizations, so patients receive the care theyneed without unwarranted delays.



Other concerns that can benefit from computerization:

Maintaining efficiency--Experts point out thatbehavioral healthcare is being downsized in manyorganizations and computerization allows agencies tomaintain standards even when personnel and budgetshave been slashed.

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Enhancing patient care--Modules match patients withthe "right" provider: For example, some patients mayneed someone who is female and speaks Russian.

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Analyzing and modifying treatment--Group Health hasrecently put in place a system that allows theassessment of populations individually, so as to look atthe effectiveness of treatment over time.

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Saving money--Instream notes that electroniccommerce can provide extensive savings to a managedcare organization, in great part by cutting down on thepersonnel needed for data processing. In its model forInstream, Towers Perrin estimated that usinge-commerce, the average managed care organizationwould realize a 140 percent increase in net income,plus an overall decrease in operating expenses.

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Saving time--Most programs have a feature that allowsstandard information like the provider's name, ID, etc.,to insert automatically in the appropriate fields. Thatmeans the time the provider spends entering the samedetails from form to form can be used to eithercomplete different details or shift back to clinical work.

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The bottom line, say the experts, is that technology andbehavioral healthcare must work together. According to LesRuthven, PhD, president/CEO of Preferred Mental HealthManagement (PMHM), Wichita, Kan., a company thatarranges and manages behavioral healthcare services for atleast 50 national companies covering 600,000 lives:"Managed behavioral care cannot be done competentlywithout the technology to handle it. We have to make use oftechnology. But it can't make up for experts in the field.Clinical judgment is still very important."

Deciding where to startMarlan Crosier, MIS manager for Behavioral Health Systemsof Group Health of Puget Sound, Seattle, says the technology"falls into place" once his organization decides what it wantsto do.



Crosier's advice might sound simplistic, but it's actuallyrepeated in one form or another by other IT experts, whetherthey're working inside an operation or outside. "The first thingwe ask every client is to define their problems," Gerner says.

For example, the Texas Commission on Alcohol and DrugAbuse came to WorkFlow Designs for a way to keepinformation moving smoothly from all sorts of behavioralhealth experts with various types of computers. The companyrecommended focusing on the lowest common denominator(for example, the field agent with a beat-up laptop instead ofthe caseworker with the best equipment in Dallas). Thesolution was a Web browser for what is now the BehavioralHealthcare Network.

Porter says one productive step they've taken is compiling a"wish list" of what they need from a behavioral healthcaresystem. Among those needs: a free flow of data among thenetwork's 10 locations throughout Connecticut and anelectronic medical record.

One of the most important aspects of Porter's wish list is theability to track behavioral healthcare across various levels.She explains, "Generally, managed care is concerned withtracking illnesses across one episode. A patient is admitted,then discharged. That's one episode." But in behavioralhealthcare, a patient can move across several levels of care,from outpatient to day treatment to inpatient care, and it's allconsidered part of the same episode.

Crosier and his team also don't reinvent the wheel. "We'vefound the organization's general medical system works prettywell in behavioral healthcare," Crosier says. "We each use thesame system for claims, billing, pharmacy, makingappointments, tracking visits, etc." Group Health uses IBM orTandem mainframes. The software includes StatisticalAnalysis Software and a number of Microsoft products(including Access and Excel). Crosier adds that they useMicrosoft for at least two reasons: It's always easy to findpeople to work on these programs, and they feel theestablished company gives them a solid upgrade path.

Having information technologists around at the beginning isnot enough, however. Experts agree that regular contactbetween IT and behavioral healthcare professionals is critical.Crosier says it's important that he's actually part of GroupHealth's Behavioral Health division "and not off in another



tower somewhere." He understands the real problems of thehealthcare professionals, and that they're not computerexperts. This understanding helps him find technologicalsolutions that are as painless as possible for the behavioralhealthcare workers.

Michelle Hertel is MIS director of PMHM. She believes thatworking her way up through different departments has notonly allowed her to truly understand--and better solve--eachdivision's problems, but to do so in a way that integrates eachdepartment's individual solution into PMHM's system as awhole. To further enhance communication between Herteland the rest of the organization, directors meet at least everytwo weeks.

Saving face timeAt Magellan, this kind of interface can perhaps best be seenby work that was needed to allow the convergence of threeclinical systems that were handling about 90 percent of thebusiness. Magellan handles behavioral healthcare for threetypes of business: HMOs, employer unions and the publicsector (Medicaid). Hawes says IT planning, begun two yearsago (even before the three companies from which Magellansprang, merged) was to develop the clinical system for theHMO business, which is the least complicated. But how doyou keep that plan fresh, given the changes in both behavioralhealthcare and technology?

The answers: For two years, information and ideas haveflowed back and forth. Additionally, a model office--designedto actually test revised concepts and new technology--wasbuilt in Columbia, Md. Last spring, the work culminated withabout 22 reps from across the company--including variousbehavioral health experts--spending two weeks on-site at theoffice to do a complete functionality review before signing offand saying "Yes, we can use this."

Maintaining confidentialityConfidentiality is a major issue when computerizingbehavioral health records. The Web site for the AmericanCollege of Physicians contains dozens of articles in its journalin which doctors talk about what (if any) information can besafely entered into a patient's chart--and the various computeroptions to choose from.

Courtney Ruthven, PhD, executive VP of PMHM, notes thathaving licensed psychologists act as case managers is one step



toward solving confidentiality issues. After all, she says, if amanaged care organization case manager contacts a providerto receive more extensive details on a patient's condition andfurther treatment is deemed necessary, the information isbeing exchanged between two professionals bound byconfidentiality agreements.

Still, privacy remains a key concern in behavioral healthcare.Muzilla notes that Instream runs on Windows 3.1 or 95. Hebelieves it could run on a Mac with emulation softwarerunning OS 7 or later. The software provides a privatenetwork, based on TCP/IP. All data is encrypted in a 128-bitdata encryption private key, using the messaging protocolSMIME.

Even with such assurances, many organizations opt to keep allcomputerized records on-site. PMHM has about 30 Pentium200s (plus some 100s for basic clerical work), running acustom database using Paradox 3.5 for DOS with both aNovell and NT server. The intention is to move to VisualFoxpro with Windows. "Our patient records are not accessibleto anyone outside the network," Courtney Ruthven says.Further, no clinical information is available to unauthorizedpersonnel. "The claims people would see a diagnosis, likedepression, but they wouldn't get any clinical details, such aswhy this person is depressed."

Wendy J. Meyeroff is a healthcare and computer writer andRichard E. Meyeroff is president of Meyeroff ComputerConsultants in Brooklyn, N.Y.

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