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The Coalition of Behavioral Health Agencies, Inc. Coalition Briefs
An electronic circular of the Coalition's Center for Rehabilitation and Recovery
No. 92, April 2013

The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.

Health Information Technology: Blessings, Disasters, and Recommendations: An Interview with Scot M. Silverstein, MD

We’ve heard a lot about the presumed advantages of health information technology (IT), but we know little about its possible downsides. To find out about this side of the story, newsletter editor-in-chief Elizabeth Saenger, PhD, interviewed Scot Silverstein, MD, arguably one of the country's top experts on health IT, and a passionate critic of some current practices.

Question: What is health information technology?

Dr. Silverstein: It is a type of computer software, supported and running on hardware, that attempts to provide computer automation to the bookkeeping, record-keeping, and operational aspects of provision of healthcare. So it is to medicine what the kind of IT used by, say, FedEx, is in shipping and tracking packages.

I do want to emphasize health IT goes beyond the concept of the electronic health record. In fact, I now consider that term an anachronism, because we are not talking about systems to replace the paper charts you see in your doctor's office. We are not talking about an innocuous record-keeping system anymore. When a hospital, or healthcare organization, or city talks about implementing electronic health records, what they really mean is that they are implementing a kind of enterprise-wide command and control system for clinical resources and clinical personnel, much broader than just a simple kind of electronic filing system.

Question: So this is more complicated than it would first appear.

Dr. Silverstein: Yes, because everything professionals do has to go through and be mediated by these information systems, not just their recording in charts. Therefore, any problems of reliability, confidentiality, or security of said enterprise-wide system is amplified beyond a simple electronic charting system. Orders can get corrupted. Medication information can go missing, with potential implications for patient care.

Question: What are the advantages of information systems?

Dr. Silverstein: A major one is commonly understood as improved legibility. That comes with the cost of slowing clinicians down, though, because they need to type, and especially navigate through electronic health record systems, which is not easy. Another advantage is decision support—for example, automated alerting of clinicians to an allergy when they try to prescribe a drug without realizing there is a history of an allergy. Those are the major advantages.

In addition, at higher levels, people can look at the data as usable for quality assurance benchmarking, cost analysis, and so on, all the way up to surveillance. This is hard to do from paper charts, but a lot easier to do if your data is already digitized.

Question: What are the disadvantages of health information technology?

Dr. Silverstein: Often health information technology is bad health IT. It is software that slows clinicians down by bombarding them with information, making needed information hard to find, and so forth. Bad health IT is unreliable, can corrupt data, can lose data, and is insecure.

These problems cause clinicians to have to try to work around the system deficiencies, which can lead to error.

Question: Can you give us an example of this kind of problem in mental health technology?

Dr. Silverstein:: Certainly. A couple years ago, San Francisco’s Department of Public Health paid $11.2 million for a commercial electronic records system. It was designed to improve care for tens of thousands of clients, but it brought administrative chaos to the mental health and substance abuse services in the city. Health officials lost track of millions of dollars of services, and chaos broke out.

The New York Times reported that once this system went up, mental health services reportedly plunged 55%, and substance abuse services fell 32%. These severe decreases caused alarm, because they indicated providers were struggling with the new software. Clinicians also complained that their sessions were shorter because of the excessive time needed for data entry. So that is a worst-case scenario where the city-wide implementation of the health IT system actually impaired services, including psychiatric services, for an entire population. 

The story is an example of a familiar script about poorly designed and implemented healthcare IT causing clinical chaos, and vendors blaming users, and vendors promising that the problems will be fixed in the next version. But this raises the question of why these problems existed in the current version. Why didn’t the vendors test the software?

Question: Can patients opt out of electronic healthcare records?

Dr. Silverstein:  You cannot generally opt out. You are not even asked about informed consent. You are not informed that this technology is of unknown risk, and of that risk level. When I say unknown, I am talking about the Institute of Medicine's 2012 study on health IT risk, which says, 'We do not know the magnitude of health IT risks," because of impediments to its reporting and collection.

That is sad, also in terms of problems with the privacy and confidentiality of existing electronic health records that could not happen with paper. There have been instances where medical records have been stolen in electronic form, tens of thousands at a time. There was a hospital that notified more than 34,000 patients their medical data had been compromised. You simply cannot do that with paper.

Question: How often are electronic medical records stolen?

Dr. Silverstein:  An article known as the “Wall of Shame,” in a journal for healthcare executives, noted that in 2011, the Health and Human Services Office for Civil Rights recorded 380 major data breaches involving 500 or more patients. From September 20, 2009 through December 8, 2012, a total of 18,059,000 individuals were affected by stolen data. This is due to multiple reasons involving computer security, lack of safeguards, limited hospital budgets, people leaving unencrypted medical information on laptops in their cars, and so on.

So the medical record breaches are occurring, and they are occurring in a way that could never happen with paper unless you had a U-Haul truck to steal and haul away 20,000 paper charts.

Question: What does this lack of security mean for patients?

Dr. Silverstein: The consequences run the gamut from identify theft to the potential misuse of that information in employment screening. For example, that information could fall into the hands of people who can financially profit from denying health insurance to individuals with mental health difficulties. Or people could use confidential medical information to gain care, which can create all sorts of problems for a person in terms of future misdiagnosis and incorrect care.

I know of a case personally where the director of a program was denied a promotion because a vice president had broken into his prescription records, and found out he was taking drugs that reflected being HIV positive. He sued. So the phenomenon is real, and the lack of tight security carries a significant social risk to patients whose information is stored in the systems, which is increasingly going to be all of us.

Question: What would you do to fix the problems with health information technology as a system?

Dr. Silverstein:  My first top level recommendation for getting the technology right would be to slow down the national roll-out. Instead of having deadlines for the acceptance of health IT, and forcing the technology rapidly on an entire country, I would regard health IT as a new medical innovation, and to apply the well-known, hard-earned principles of medical research to it. In other words, I would treat health IT as a new medical device. I would allow the technology to be better proven, and its safety improved in sequestered, constrained environments, in testing environments, until the information technology issues of reliability, security and so forth, are better worked out. For the time being, I would also leave paper in place where it already exists, and maybe even work on improving the paper.

Question: And your next recommendation?

Dr. Silverstein: I think the second thing we need is regulatory oversight.

It may surprise most of your readers to know that there is no regulation whatsoever of health IT of the kind one might expect in healthcare. I am not referring to the software inside an implantable defibrillator or something like that, but to what the Food and Drug Administration calls electronic health record systems. The FDA deems them medical devices, but they are not regulated. Even the current government certification program is really just a pre-flight checklist. There is no testing for safety. There is no testing for efficacy. Pharma IT used in drug manufacturing and clinical studies has to be FDA validated, and inspected, but on the provider side, there are no such requirements. I think there needs to be.

Who should be responsible for that regulatory oversight is unclear. However, they should have regulatory teeth. They should have experience of doing this sort of thing.

So my two recommendations would be to slow down, and regulate, to do things in a more sane fashion, rather than with the kind of mania that health IT is being spread now.

**** Further Reading on Health Information Technology ****

Wrong records and failures in data transfer impede physicians and harm patients, according to an analysis of health technology incidents in a 2013 American Medical News article, Ways EHRs can lead to unintended safety problems.

The 2013 RAND report, What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology, provides a realistic picture of how we can fulfill the promise of health IT.

In Health IT and Patient Safety: Building Safer Systems for Better Care, the Institute of Medicine of the National Academies of Sciences notes severe health IT risks and safety issues, recognizes that health IT is unregulated, and admits it does not know the magnitude of the risks.

In Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records, the National Institute of Standards and Technology observes that commercial health IT is not very usable, creating lost efficiency and risk, and much indicates specific changes needed to make electronic health records user-friendly.

Interview edited for the Coalition of Behavioral Health Agencies, Inc.



Op-Ed: The Provider/Family Relationship: An Opportunity Ready to Happen?

- Judith Carrington

The New York State Office of Mental Health (OMH) began generous support for family psychoeducation as a “Best Practice” a decade ago, when over 30 randomized clinical trials showed that the Multifamily Group form of family/consumer/provider education could reduce relapse rates from 40 to 53% down to 2 to 23%.

OMH instituted important incentives: the Intensive Rehabilitation component in Comprehensive Personalized Recovery-Oriented Services now reimburses for Family Psychoeducation; Assertive Community Treatment (ACT) teams are required to give “support, education and skill-teaching to family members,” and OMH’s Family Institute for Education, Practice and Research is pioneering with agencies the possibility of a maximum of three family meetings and a range of family programs.

However, feedback from the field reveals a disappointingly low response for family participation. Focus groups and surveys with National Alliance on Mental Illness (NAMI) affiliates show that families are not always aware of the role they play in their loved ones’ recovery; how they are supposed to be involved in treatment and discharge planning; and what information, education, and ongoing support programs they are entitled to.

We do know that upon entering the mental health system, families are at their most impressionable, trainable point, and highly motivated to learn about encouraging recovery for their family member or friend. However, there have been few self-help materials for families with a family member inpatient as he or she graduates to outpatient, and faces a lifetime of challenges.

Consequently, OMH and NAMI New York State underwrote the first Family Toolkit. Authored for and by families for use in and out of the hospital, the three-part Toolkit offers a pamphlet of “rights” for families; a Handbook of practical, “how to” information, and resources; and a booklet examining confidentiality law from the consumer/family/provider perspective, available here.  It has been hailed by the Director of New York State Psychiatric Institute, the Executive Vice Chairman of NewYork-Presbyterian, and the psychiatric nurse leadership at Coney Island Hospital, among others.

The Family Toolkit addresses the need for families, at earliest entry into the mental health system, to obtain direct, honest, practical self-help, information and education about how, in a matter of days, to take on part of the job of a Case Manager. The Toolkit’s goal is to make families effective members of the recovery team, and dispel their sometimes earned reputation for being over-demanding, over-emotional and time-consuming.

If educated, families can work with clinicians to help individuals in the process of rehabilitation. The ability of families to partner with professionals to make a significant contribution to recovery is an opportunity ready to happen.

Judith Carrington, initiator and primary author of the Family Toolkit, founded Mental Health Resources. She conducts a Peer Family Coaching practice, and can be reached at mail@mentalhealthed.org.


The Good, the Bad and the Unconscionable

- Marylou Selo

I returned home after guiding a 10-day bus tour through the southern United States. I went to the bank, changed my generous tips into one dollar bills, and threw them from my balcony, happily shouting, “Merry Christmas in July!” It was a wonderful feeling of sharing “wealth.”

However, some neighbors were apparently concerned that I was throwing away my possessions, and would soon jump myself, committing suicide.

The Good

The treatment in the hospital was ok.There was a nurse appropriately named Angel, who was kind and willing to listen. There was Jamaican Jim, who taught Yoga at night to pass the time.

The Unconscionable

There was no air conditioning on the psychiatric unit, a killer for patients on psychotropic meds!

Shortly before discharge—not because I was better, but my insurance was to run out after 12 weeks—the social worker told me in no uncertain terms that I was “disabled.”I would never be able to work again. I better find a hobby to get through endless days of nothing to do, and all day to do it. He offered to fill in papers for disability payments.

I wanted to shout, “I will work better and longer than you, you Idiot!”However, since I wanted to be discharged, I took a deep breath, and said, “Thanks, but that will not be necessary.”

The Happy Ending

After the lithium kicked in, I have worked better than ever!


The Latest Research
- Elizabeth Saenger, PhD

Mental Health Courts

Goodale G, Callahan L, Steadman HJ. What can we say about mental health courts today? Psychiatric Services. 2013;64:298-300.

Mental health courts are specialized, problem-solving courts designed to reduce recidivism by correcting what many see as the unmet needs of defendants with a psychiatric diagnosis. Typically if such individuals are charged with less serious crimes, agree to a guilty plea, and meet other eligibility criteria, they can choose the equivalent of a treatment plan from a judge. These arrangements include a combination of incentives, such as help finding stable housing, and restrictions, such as abstention from drugs and alcohol. If monitoring indicates an initial warm and fuzzy initial approach is not working, judges may incarcerate defendants.

Goodale and colleagues find most studies show that mental health court participants do better than treatment-as-usual controls on the two outcome measures generally considered: involvement in the criminal justice system, and participation in community services. For example, one of their studies found that participants in California mental health courts had a lower rate of recidivism (10%) compared with similar non-participants (25%)--a 15% difference. At the same time, mental health court participants also accessed community resources more rapidly, and had more intensive therapeutic contacts, and these activities were associated with symptom reduction and an improved quality of life.

Nevertheless, like other researchers, Goodale and colleagues discovered no relationship between the kind of therapy received, and the likelihood of re-arrest. They speculated that the magic ingredient that lowered recidivism might be "some combination of intensive monitoring and supportive relationships with mental health court staff" (page 299). Similarly, in voluntary psychotherapy, much of a client's progress is due to relationships, namely the strength of the therapeutic alliance, rather than the particular paradigm of treatment.

Given the accomplishments of mental health courts, Goodale and colleagues hope they will grow through funding in the Affordable Care Act, which requires health insurance plans to cover such treatments regardless of whether they are court-ordered.

I think these courts may be a mixed blessing, however. On the one hand, the drop in recidivism to less than half of what it would otherwise be raises the question of whether a problem-solving, supportive, interdisciplinary court system might be helpful for a wider range of defendants, not only ones with psychiatric diagnoses .

 On the other hand, I wonder whether mental health courts have unintended consequences that Goodale and colleagues may have overlooked. As the Bazelon Foundation notes, these specialized courts reduce the volume of defendants in jails already full to the brim. Alleviating this pressure decreases the incentive to reform a system which brings involves so many people with mental illness in the criminal justice system. In short, investments in safe, effective, voluntary interventions, both for people with and without diagnoses of mental illness need to be made sooner.

Collaboration, Empathy, Accessibility, and the Bottom Line

Sylvia LG, Hay A, Ostacher MJ, et al. Association Between Therapeutic Alliance, Care Satisfaction, and Pharmacological Adherence in Bipolar Disorder. J Clin Psychopharmacol. 2013 Apr 19. [Epub ahead of print]

It may come as no surprise, but with every study on the subject, it's becoming more official: patients' relationships with their providers seem to affect outcomes. In this particular study, Sylvia and colleagues conclude, "Patients' perceptions of collaboration, empathy, and accessibility were significantly associated with adherence to treatment in individuals with bipolar disorder... Patients' perceptions of their psychiatrists' experience, as well as of their degree of discussing medication risks and benefits, were not associated with medication adherence."

These findings imply provider relationships skills may be among the most essential tools of psychopharmacologists, because, as the saying goes, a medication won’t work unless you take it.

However, given that we know that relationships are critical in clinical care, why aren't people skills considered as seriously as academic grades in admission to all medical schools and graduate programs in clinical psychology, social work, and so on? Why do so few medical training programs try to teach empathy by, for example, subjecting students to voices they cannot turn off to show them how distracting auditory hallucinations might be?

Psychiatrist Peter Weiden once described how he developed a form of cognitive behavior therapy to increase adherence in people with schizophrenia. While the clinicians he taught were enthusiastic about trying this intervention, the hardest part for them was to allow patients to describe medications as ineffectual, or to suggest other treatments they thought might be better. Consequently, Weiden joked, he kept a roll of duct tape in his office to remind everyone, including himself, that when they wanted to interrupt a patient, they should imagine duct tape on their mouths.

Patient outcomes might improve if relationships skills were a prerequisite for providing all clinical care—and so might the power structure, if promotions depended, in part, on bedside manner.


Balanced Guides on Treatments in Behavioral Health—Free!

The federally-funded Agency for Healthcare Research and Quality (AHRQ) creates free research summaries about different health conditions, including mental illness. AHRQ comparative effectiveness reviews of treatments cover health topics suggested by the public in an evenhanded way which points out the limitations of the data, so you know how confident you can be about conclusions.

Depending on the subject, summaries are available for consumers, caregivers, clinicians, and policymakers on different subjects within Developmental Delays, ADHD, Autism, and Mental Health.



Center Education and Training

For more information, or to register, please visit us at http://www.coalitionny.org/the_center/training or email Deborah Short at dshort@coalitionny.org.

Psychiatric Rehabilitation 101

Facilitator: Amanda Saake, LMSW

Date: May 21, 2013          Time: 1:30 pm – 4:30 p.m

Location: 90 Broad Street, 8th floor, Conference Room

Recovery is the goal and Psychiatric Rehabilitation is a vehicle to achieve this objective. In this training, we will introduce the Psychiatric Rehabilitation philosophy and practice, with an emphasis on operationalizing skill development theories.

Working with People Coming out of Institutional Settings

Facilitator: Amanda Saake, LMSW

Date: May 29, 2013          Time: 1:30 p.m. – 4:30 p.m.

Location: 90 Broad Street, 8th floor, Conference Room

This training will focus specifically on what community mental health programs can do within the scope of their existing services to inspire a belief in recovery and a sense of hope in the future in people coming out of institutional settings including nursing and adult homes. The training will also cover the integration of these new participants into the existing clinical population.

Cognitive Behavioral Techniques & Skills Development in Group Work

Facilitators: Amanda Saake, LMSW and Laura McLeod

Dates: June 3 and 17, 2013           Time: 1:30 p.m. – 4:30 p.m.

Location: 90 Broad Street, 8th floor, Conference Room

Groups are an important clinical tool in mental health services, and with an increasing emphasis on recovery, understanding cognitive behavioral approaches and skill based group work is essential. This training will focus on the behavioral techniques that motivate group members to take an active role in their own recovery. Participants will also learn how to address individual problem behaviors and group-level resistance that can undermine progress.

Introduction to Benefits Management

Facilitators: Margie Staker, CQSW & Patricia Feinberg, MS, Certified Benefits Planner

Date: June 6, 2013           Time: 9:30 a.m. – 12:30 p.m.

Location: 90 Broad Street, 8th floor, Conference Room

This half-day training will introduce clinicians and other staff to benefits, and the details of benefits management. The latest changes in Social Security Administration guidelines will also be discussed. Participants will:

  • Review the fundamentals of the Social Security System
  • Distinguish between SSI and SSDI, and between Medicaid and Medicare
  • Discover resources that support consumers in their living and working goals
  • Learn to help consumers effectively use benefits to support their recovery

Dylan’s Law

Facilitators: Pat Feinberg at CCRR, Jody Silver, DOHMH

Date: June 24, 2013         Time: 1:30 p.m. – 4:30 p.m.

Location: 90 Broad Street, 8th floor, Conference Room

This workshop will focus on research that reveals very specific ways a dog can be trained to help a person coping with psychiatric symptoms, such as disorganization, memory loss, irritability, anxiety, fearfulness, and hyper-vigilance. Helpful websites and training programs, as well as criteria for finding the right dog or other animal especially for you or the people you serve, will be described.

Opinions in this newsletter may not reflect the views of the Coalition for Behavioral Health Agencies, Inc, or the editor.




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