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Two Steps Forward, One Step Back

Posted By Ben Miller, Tuesday, August 3, 2010
Updated: Thursday, June 2, 2011

In the current redesign of healthcare, there is precious little time for meetings to discuss what should be done next. The convening of various healthcare stakeholders to Baltimore, Maryland for the URAC/HAYES Paul Wellstone Mental Health Parity Stakeholders Conference was a unique opportunity for dialogue to occur around the future of mental health. This meeting was timely and precise in its attempt to examine the impact of mental health parity on current healthcare legislation, clinical practice, and payment strategies. There were three main points that emerged from the meeting that I will briefly address.

First, there appears to be growing sentiment that mental health parity is an important step for mental health treatment, but remains insufficient. Mental health parity law is in direct response to the fragmentation of the healthcare system. From an insurance perspective, parity brings mental health on an equal footing with medical benefits. This is a positive step for individuals in the community who need access to mental health services, but have previously been unable to access due to insurance barriers. However, it is important to note that just because insurance barriers have decreased does not mean more people will access mental health services. For example, we know that the majority of the public receives their mental health care in primary care, and that when referred to outpatient mental health, they often do not go. This may not change just because one has insurance to pay for services.

Second, within the redesign of primary care in the patient-centered medical home (PCMH), there is an increased opportunity to make the case that mental health and substance use must be included. While many know of the inseparability of mental health from primary care, this point still needs to be made every time the PCMH is discussed. The integration of mental health providers into the PCMH is one possibility for primary care’s redesign; however, mental health needs to constantly be at the table of discussions on the PCMH for this to happen. While this is just one future for mental health, acting now and acting fast is key to success as the fluidity of primary care’s redesign will not stay this way long.

Third, more research is needed to support the importance of mental health in the larger healthcare system. Without enhancing the evidentiary support for mental health and psychological treatment in medical settings, recommendations will be anecdotal and possibly ineffective. A golden opportunity could be missed. At a point in our nation’s history where we are looking to "bend the cost curve” and provide higher quality more effective and efficient care, our arguments should be grounded in science. There are many examples of this type of research happening now throughout the country. Mental health providers interested in the future of their field should consider using similar measures, tracking similar outcomes, and sharing this data so a stronger "business case” can be made for integration. Yes, there is a robust literature base on psychological treatments for medical conditions, but they have predominately been disease specific and limited in generalizability. We need more effectiveness trials that look at the heterogeneity seen in our healthcare settings.

There are rare opportunities in healthcare where systems can be profoundly impacted by their redesign. This may be one of those times. While mental health parity brought a group together in Baltimore, the passage of the bill itself was more confirmation of how far we still have to go. Dichotomizing mental health from physical health is a false separation. Two systems have developed from our inability to treat the whole person. Will healthcare providers of all ilks be able to rise to this momentous occasion and define itself in a new system? Will we be able to know what our future looks like and actively work towards this point? As I outlined above, there are many opportunities for mental health to become a major player in healthcare. Are we willing to take the risk? Are we willing to innovate? The choice is entirely up to us; but make no mistake, if we do not move, and move now, we will be left behind fighting for another version of parity in 10 years.

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Collaboration Haiku

Posted By Randall Reitz, Tuesday, July 27, 2010
Updated: Thursday, May 26, 2011

As the CFHA Conference in Louisville fast approaches, the collaborators of the world are abuzz with creative energy. What better way to channel that enthusiasm than by writing a short Japanese poem? You loved haiku in 4th grade, now that you've finished grad school, you are a Haiku MASTER.

This link will take you to a brief video synopsis of how to write haiku. Traditional haiku maintains a very tight formulation of 17 syllables, 3 lines, 1 season, and the creative juxtaposition of 2 disparate images. As with all things American, new world haiku tend to be more free-form and include the profane with the natural. For example, a favorite website of mine boasts over 19,000 haiku dedicated to spam, including this gem:

Post-SPAM catharsis:

Peptic acid and pink chunks

Floor-mount Pollock piece

Please take a minute to add your own haiku about collaborative care or your aspirations for the upcoming Louisville conference. I'll get us started with:

Reform the system

Discover self among peers


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Medical Family Therapy: Integration Into Healthcare

Posted By Jennifer Hodgson and Tai Mendenhall, Monday, July 26, 2010
Updated: Thursday, June 2, 2011

Medical Family Therapy (MedFT) is inspired by many people from several different professions. It has made a nest under the umbrella of Family Therapy by nature of its attention to the family unit, systems thinking, and relational foci. However, when it comes to practicing MedFT, numerous professions embrace and apply its concepts. My intent in this piece is to briefly introduce two core concepts (of many) that form MedFT’s foundation and articulate how they represent an asset(s) to healthcare.

Foundational Concept #1: Relationally-Minded. Medical Family Therapists, while generally viewed by others as professionals who are skilled at providing family therapy in medical settings, they see their role in a considerably broader frame. They work systemically with individuals, couples, parent-child subsystems, and can facilitate health behavior groups across a variety of mental health and physical health conditions and illnesses. Their work with relationships also extends out to the providers within the healthcare team and across the healthcare system. At times this looks like comforting a nurse who just lost her mother, sitting with a NICU resident who lost a baby in his care, calming down a physician who just found out that her patient is selling his pain medication at the local high school, or spending time figuring out how the clinical administrator can delicately reassign offices to accommodate a new hire. They see situations as having systemic impacts and help patients and providers to solve difficult relational issues. Where some may find comfort in working exclusively with the individual and see the support persons around the patient as data gathering assets, MedFTs believe that the more people in the room with the patient while the intervention is happening, the faster the change and greater likelihood of its sustainability.

Foundational Concept #2: Integrated/Collaborate Care Advocacy. Medical Family Therapists are trained to provide integrated and/or collaborative care in primary, secondary, and tertiary care settings. They recognize that without integration of care, patients will continue to fall in between the cracks of the healthcare system. MedFTs are trained to know and understand the culture(s) of medicine and have tremendous respect for it. They respect the ethical and reimbursement challenges that exist when integrating care and work to construct models that combine providers’ ideas into one shared treatment plan. They find the patient and family unit (as defined by the patient) to be critical partners in that process. You will also find MedFTs at the table drafting policy, designing models of integrated collaborative care, and running behavioral health components within healthcare settings. They are change-agents that help medical systems to thoughtfully integrate services in a manner(s) that pays simultaneous attention to the overlapping views and interests of the clinical-, operational-, and financial- worlds of healthcare.

It is through the advancing of these concepts (again, among others) that Medical Family Therapy is defined. Today there are several certificate and degree-granting programs in MedFT across the master’s and doctoral levels; within these programs the amount of education given regarding relational interventions and integrated collaborative care may vary, but these areas are consistently an important part of the curricula. This is important to note because not all family therapists, psychologists, social workers, or counselors who do family work are trained to do MedFT, and not all MedFTs are trained family therapists. And while MedFTs are not being defined as a independent profession currently, recent research shows that they are headed in that direction.

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Who's the Boss of Me?

Posted By Peter Fifield, Wednesday, July 21, 2010
Updated: Thursday, June 2, 2011

Good Question. A few weeks back my almost three year old son and I were looking at a poster of the 8 planets. After reviewing the names together it was his turn to try solo. He began with the sun then to the subsequent planets--pointing to each one he said "Mercury, Venus, Earf, Mars, Jupatewr, Saturn, Myanus, and Neptewn”. I offered him encouragement for his job well done and of course just one correction…”Isn’t it Uranus” I asked him with a slight grin. "No it’s mine Papa!” he insisted. At that point I could not help but appreciate what ownership he had of his body. Later, I asked my wife "At what point do we lose that ownership”?

It is hard to deny that many social psychology concepts have great significance regarding our health. Three different yet somewhat related topics come to mind. Diffusion of Responsibility, The Bystander Effect and Social Loafing—all of which basically state, the more people whom are involved in a situation, the less likely anyone will take responsibility for the outcomes of that situation. Usually a population greater than 10 is needed to see these social phenomena at work. I can’t help but speculate that maybe there is a direct connection between these concepts and the state of our health care conundrum. Has our society created a nanny-istic health system that has become so protective of its patrons it has reached a point of harm?

Why do I have to look out for my own health? Why should I do it when someone else will? Due to many driving factors we have managed to medicalize most chief complaints presented in the primary care setting. Complimenting these sometimes "every day” medicalizations are a salvo of pills; a synthesized solution for the infirm. It is no wonder why the US is last in healthcare, we are trying to fix things that aren’t fixable or even broken--they are to some degree, just normal. My challenge as behavioral health provider is to empower people to be healthier but I continue to ask myself "Who am I to think I have the power to give back to them in the first place?

So this leads to the pressing question of how do we make this happen? How do we get people to become more possessive of their own heath and stop relying so much on medical intervention? How do we not only shift but balance our philosophical approach so people see their health as their responsibility not someone else’s? How do we as health care providers promote patient autonomy? Concepts such as collaborative patient centered healthcare, and the use of social media options as well as new medical technologies such as EMR’s "Health Apps ” for smartphones and other Health Information Technologies can make this job easier but there has to be more.

How did we end up creating this society based on health nannying…a sort of protectionist approach that conversely demotes the need for personal discretion and accountability? Maybe through the medicalization of our lives we adopted a social loafing perspective of ourselves; or maybe it is a case of learned helplessness. Either way we should adopt a new healthcare mantra like "I’m the boss of me”. I’m not sure when it happened but somewhere down the line we have managed to give someone else the power over our wellbeing. We have to work on taking it back. We have to somehow create a balanced healthcare delivery system where public and private sponsored healthcare options create a conduit that facilitates access to quality and evidence based care and simultaneously creates a venue where people have personal autonomy and accountability to themselves.

Typically when I find fault in a process I try not to opine unless I have a few potential solutions. Who do we blame for this mess: the medical model, the mere existence of health insurance, the need for a listed cause of death on death certificates or the drug companies—maybe all of the above? I’m at a loss here, possibly due to the magnitude and complexity of it all. That being said, this topic is too important, to forego a comment this time around even though I have no proposed solutions. Ultimately we have to ask: How do we shift the healthcare paradigm and truly allow people to be accountable for their health. Then we have to ask, "what do we do” if they don’t want it.

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Can Social Technologies Help a Healthcare Professional Organization?

Posted By Gonzalo Bacigalupe, Tuesday, February 23, 2010
Updated: Friday, June 10, 2011

Julia, an active board member of a health care professional organization, noticed my recent twitter activity, such as:

Paternalism, participation & partnership: the evolution of patient centeredness in the consultation> <> #cfha

What physicians should discuss with families in relation to brain-activity? <> @NEJM

WashingtonPost: Experts Defining Mental Disorders Are Linked to Drug Firms> <> #dsm5

Financial Ties between DSM Panel Members & Pharmaceutical Industry #dsm5 (referee article) <>

Are people who sell Dickens novels depression enablers? #dsm5 generalized fail disorder <> @Adisson89 @helio_girl

Doctors need to EDUCATE THEMSELVES about complex ethical issues; they drop the ball with #BlackPatients on this all the time

What physicians should discuss with families in relation to brain-activity? <>

#behavioralhealth: Listening is good in #primarycare #cfha blog <> @miller7 @eastcoastkid01

Harvard Vanguard offers shared appointments. Great idea: meet w/your MD & other patients for 90 minutes #hcsmeu

Julia was intrigued by the possibilities that Twitter and other social technologies could offer to the organization in which she is a board member. How could these technologies help us in doing our work? Our members are located all over the world and some of us meet annually during a three days conference at some hotel. Sound familiar? After a few email exchanges and recognizing the difficulty at having a good discussion in which we could talk about what the question meant and the complexities involved in drafting some strategic plan related to social media, we set up a phone conversation to brainstorm.

For this organization, I suggested, the initial goals may be to set up a virtual office to archive the organizational memory of this professional association. At the moment, the documents are probably filed at various offices of former and present board members. Members could archive the organization documents at a secure server but could also just upload them to a GoogleDocs account. The same set-up would allow various members of the board or committees to work on shared documents rather than getting confused with email attachments. Having the documents in a server could allow the organization to share them with everyone or a selected group.

How about a Wiki? I ask. With a wiki, board members could upload and download documents and at the same time display them. The wiki would also allow members to have threaded discussions. In the later case, the group could use the freely available wikis or pay a small sum and have a wiki that could be shaped according to their own identity. These two simple technologies are so easy to use and it is amazing how many organizations or groups seem either unaware or a bit resistant to use them.

A second goal would be to strengthen the ability to maintain transparent communication between and among the board and the general membership. For that, I suggested that the organization webpage could add a simple WordPress blog. The blog could be open to everyone arriving to the website or it could be password protected. If the board was worried that the entries could be not appropriate for a professional organization, it would be very easy to just set it up so that a board or various board members approve the publication of the comments. Like wikis, setting up a blog is a fairly straightforward procedure and it can become a terrific vehicle to share something and then engage all comers in the dialogue.

When we arrived to the issue of Twitter, we talked a lot about the hash tags. Like the ones some of us use to identify an entry that may be of interest to CFHA members. In this case #cfha <> , creating a hash tag and "owning it" via What the Hashtag?! <> By creating a hash tag, anyone could enter into a dialogue that it is relevant to the organization without requiring all members to follow each other's tweets directly. Hash tags also help groups to generate discussions.

During the conversation, Julia asked me about Facebook. Would Facebook help us network? My response was less positive when discussing Facebook. I have found that at least two important issues emerge when thinking about Facebook in relation to professional organizations.

One, a lot of professionals are concerned about the issue of privacy. If they have an account, they think that joining a group will mean that everyone in the organization will know about their private lives. It is not the case but it is hard to explain and the concern is persistent, in part because of fear and in part because Facebook made some bad decisions in this regard at various points of its evolution. There are other concerns, for many, Facebook is still a mystery, despite the tremendous growth, many join and then they don't have a clue of how to manage it or even login back again.

And two, if one is able to overcome these hurdles, I have found that Facebook groups are for the most part not very active. The problem is that members of groups are not able to know if new information is being shared unless they visit the group. Therefore, groups grow but then they become sort of a static shared webpage rather than an interesting and evolving dialogue among peers.

My advice to Julia was to try LinkedIn and to motivate a few members to join twitter and begin using it to discuss issues of interest. LinkedIn is popular among those trying to get a consultation gig or are looking for a job. For an organization though, LinkedIn offers the ability to organize groups and the interface is less distracting. For the adventurous, I told Julia, setting up a Ning social network group for her organization would be a great way of consolidating the features we discussed. But Ning will require a larger commitment and it may not be as compelling to her core membership.What are your professional association social networking needs?

Have you started thinking about moving some of the annual activities into a virtual platform?

Will these social technologies generate more interest in becoming a member of your organization?

Or, the contrary, people will ask themselves, why do I have to pay for membership in this organization if we can just organize via the digital technologies?

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Listening is Good Medicine

Posted By Peter Fifield, Monday, February 8, 2010
Updated: Thursday, June 2, 2011

The National Day of Listening happens every year, the day after Thanksgiving. I know it was a while back but due to both a past blog and a recent patient encounter I began thinking about this concept again. This year during National Day of Listening, I chose to interview my father. He has lived a fulfilling life in his 78 years. When we sat down to kick the "interview” off he, with sincere curiosity, asked "You are not doing this because you think I’m going to die are you”? After I debunked this myth of his, we proceeded. With a digital recorder on the table, we sat and talked over coffee for about two hours. My entire life, I have had a great communicative relationship with my father but something was different this time. This time my sole intent was just to listen, nothing else. I had no intentions, no predispositions, no expectations, just open ears. I learned a lot about my father that day that I had never known before.

For a Behavioral Health Consultant (BHC) in a primary care setting, this happens (in a much abbreviated fashion) on a daily basis. We learn about our patients through listening to them. A recent web article puts communication third on the list of things patients want from their providers (after eye contact and partnership: two other integral parts of communicating). Communication as we all know is bidirectional—both inquisitive and declarative—and as many surveys have pointed out, patients want more in terms of healthcare than just to be told what to do. However, in a world of fifteen minute fee-for-service health care visits this has proven to be quite difficult for the average primary care provider (PCP) to perform. PCP attitudes regarding this high level of communication vary from virtually uninterested to dutiful: I have worked with both.

During the onset of the 20th century, Sir William Olser counseled his Hippocratic brethren to "Listen to your patient, he is telling you the diagnosis”). Why is it that so many patients still complain that "my doctor doesn’t listen to me? Well because they don’t…at least not to all of it. The Happy Hospitalist states quite clearly that doctors do ignore patients, because they have to. PCP’s need to filter what they hear in order to provide accurate, succinct and timely care for their patients. That being the case, where is the middle ground? When over 70% of patient visits in the primary care setting are psychosocial driven—how can the PCP, proffer an environment where patients can express not just their physical but their psychosocial needs? And of course, now fit all of this into a 15 minute slot (including charting). One option is to utilize Motivational Interviewing (MI) skills designed for the primary care setting. Although this approach necessitates some practice, the learning curve is not too steep and the average Joe, can adapt rather quickly. This MI approach requires the strategic use of certain communicative tools, that allow one to express empathy, develop discrepancy, work with patient resistance and support self efficacy (Miller & Rollnick).

For a growing number of primary care offices, the BHC is a viable option to fill this void—we get paid to listen. As Sir William Osler so pithily stated, listen to your patients. The BHC can enhance the PCP’s ability to hear the patient’s needs—not replace it but enhance it. Although it sometimes happens, the concept is not to merely pass off a rambling patient to the BHC because the PCP doesn’t have time and the BHC does. The BHC role is to improve the diagnostic and treatment abilities of the PCP. Two sets of ears, listening from two different and distinct perspectives to the same set of symptoms.

Recently, after an initial 15 minute consultation w/ the PCP and a new patient I was hugged by the patient in the exam room. Upon leaving she said "Thank you so much for just hearing what I had to say, I felt like no one was hearing me, no one”! We all have a story, and I listened to hers. Interestingly enough, at no point during our consultation did she mention any medical indications. She has returned a few more times since for follow up and Hypertension has been removed from the problem list. Now I’m not so naïve to think that all medical ailments can be healed by merely lending an ear, however; patients are the experts on themselves, they just need help interpreting what they know. Listening is a mean to this end which makes it good medicine.

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Collaborative Care Throwdown

Posted By Jennifer Hodgson, Thursday, February 4, 2010
Updated: Thursday, June 2, 2011

Have you ever watched Bobby Flay on the Food Network channel beat other chefs and cooks at their own specialty dishes? He always looks shocked when he wins but on the way to the challenge he is confident in his product. This is the exact same way that I see collaborative care models as they face off to an existing method of care. However, like Bobby, there are critical things one needs to appreciate about the context one is entering before proposing changes to it. For example:

  1. What are their signature services? What do they take the most pride in already?
  2. Who is most motivated for change within the system?
  3. What unique twists do you have on their service that would leave them interested and appreciative and not threatened?
  4. What kind of space issues do they already have? Space is not a deal breaker but how you provide your service in that space can be.
  5. What kind of training have you had in collaborative care that would make you the best match for that setting?
  6. What innovations in billing are you aware of that will sustain your position?

These are a few thoughts to get the juices flowing. What added ingredients do you need to bring to the table for a successful collaborative care throw down?

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Collaboration in an EMR Environment

Posted By Randall Reitz, Sunday, January 31, 2010
Updated: Thursday, May 26, 2011

If you're reading this blog post, you probably already know that an EMR is an "Electronic Medical Record"--or a computer-based patient chart. Describing an EMR environment is a moving target because our current healthcare system boasts 400+ different EMRs and each brand is constantly upgrading with new components.

A number of articles have been written about the strengths/weaknesses of EMRs and the risks/rewards of EMR adoption (here, here, here). This blog post will focus specifically on considerations related to the practice of collaborative care. Like any technological advance, EMRs have a ripple effect in a collaborative environment.

In some ways, adding an EMR into a primary care setting is akin to adding a mental health specialist:

  • It enhances services available in the primary care setting,
  • It improves some aspects of communication while bogging down others,
  • It challenges our basic assumptions about healthcare practices and ethics.

I'll provide my biased opinions on 5 topics germane to collaborative care:

1) EMRs both facilitate and complicate collaboration. All EMRs include an email-like tasking function for communicating between officemates. For example, suppose a lab value arrives in the physician's inbox. She judges it as WNL and forwards it to her assistant with an automatic notation to call the patient and inform him that all is good. These 3 clicks provide the full documentation required for the lab, put in place all necessary follow-up, and avoid the need to walk down the hallway looking for her assistant. It also provides for an on-the-fly paper-trail that reduces the risk that the lab value will fall through the cracks.

The same is true for integrated behavioral services. I will frequently get lab values (i.e. positive urine drug screens, thyroid values, diabetes A1c levels) for shared patients. This will prompt discussion about the best way forward. This works well for simple discussions, but bogs down for complicated decision-making that requires a face-to-face discussion. Most commonly, these messages read "Here's patient X's drug screen, positive for methamphetamine, let's discuss when I see you in clinic."

The problem is that these tasking inboxes go viral. Physicians and counselors spend hours sequestered in their cubicle "working their box". Instead of meeting with patients or networking heart of the clinic, they grow pale and flaccid clicking away. They occasional flitter off to an exam room with laptop and Red Bull in tow. Once there, they occasionally distract their monitor gaze for some eye-to-eye contact.

Equally exhausting, most EMRs allow for remote access, so people can work their box from home. This allows providers to get home at a reasonable hour, but breaks down collaborative opportunities and further contaminates the home environment with professional duties. The communication solution provokes the next communication problem.

2) Large EMRs magnify the confidentiality bugaboo. The healthcare system in which I work is adopting the same EMR across dozens of hospitals and clinics. This will allow for a consistent EMR environment, ease of information sharing, and should reduce duplicative orders that result from missing information.

On the downside, EMRs are not generally geared for collaborative settings, which causes some confidentiality concerns. For example our EMR can be programmed to have a robust Social and Family History. It also places the SFHx in a prominent place on each patient's e-chart. The downside of this is that if I put any explicit information in the SFHx (i.e. sexual abuse history, sexual orientation, criminal history) it will show up prominently when this patient sees the nephrologist, urologist, or podiatrist. The patient will be unwittingly sharing information that was shared in confidence with me. As a result, we chose to scale back on what goes into the SFHx and reserve sensitive material for counselor notes. These are still available to the entire hospital system, but require additional digging.

Similarly, one of the great successes of my community is that our physicians and hospitals invested in a regional health information organization (RHIO). Through this meta-EMR, almost every prescription, lab value, hospital record, specialist note, and imaging report is accessible in every office at a moment's notice. For confidentiality purposes, the person accessing the record only needs to confirm that s/he has access privileges based on 1 of 4 criteria (i.e. "I'm the patient's physician" or "I'm providing continuity of care services"). They call this "breaking the glass box". The system is smart enough to track which people accessed which records and produces reports regarding red-flag behavior.

However, this service is far more ham-handed with records produced my mental health professionals. My records are completely sequestered within the system and I need to send them out to other professionals one-by-one. If I don't send them, no one knows that I even saw the patient. This approach has pros and cons. The major con is that it is antithetical to collaborative care to treat the records so disparately. The pro is that this stays truer to the original mental health ethics and HIPAA laws. As with the SFHx, there is a lot of information that patients don't want shared. At the end of the day, this is probably a good thing because a confidentiality breech in a completely wired community is far worse than faxing a record to the wrong office. In the wired scenario the entire healthcare community can be exposed to the breech.

3) EMRs include cool applications and more are on the way. For example, our EMR, eClincal Works, includes built-in Smart-Forms for patient screening. This includes a PHQ-2 that self-scores and automatically prompts a PHQ-9 for positives. The PHQ-9 also self-scores and produces explanatory text directly within the patient's note. Ideally, it would also track changes in PHQ scores like a lab value, but that functioning is not currently available. eCW also includes a built-it CAGE screen.

Many EMRs include handy applications for collaborative care friendly chronic disease management. This includes disease registries, referral tracking, and self-management goal functionality. According to presentations I've seen, the next generation of these registries will move beyond disease-centric and instead focus on overall health markers for a patient that transcend individual diseases.

Future EMRs will need to better reflect the synchronous nature of collaborative care. For example, it would be ideal to have a shared note for group medical appointments and joint appointments. Each of the collaborators would contribute to one note that would reflect the entirety of the episode. I have also yet to find a good genogram tool within an electronic medical or behavioral health record. I have seen a few stand-alone software packages that create static "snap-shot" genograms, but not anything that is integrated with the rest of the record or easily updatable.

4) EMRs can reinforce the Body/Mind split. Demon Descartes would have loved him some EMR. I have yet to find an EMR that meets the needs of both medical and mental health specialists equally well. The needs and documentation traditions are different enough that it is difficult to serve two masters. So, medical and mental health records have developed in size and sophistication in separate spheres. Despite the fact that FQHC's and Community Mental Health Centers will frequently work quite closely together, they almost always do so on separate and incompatible records. In the worst cases (like my current practice), the embedded mental health workers end-up doubling their paper burden by preparing individual notes for both systems.

I have colleagues from a behavioral office who are imbedded within a large primary care office. The well-intentioned medical office offered to share their EMR with the behaviorists, but the contract with the EMR company would not allow them access unless they were all purchasing licenses as part of one corporation. The end result is that the medical office will probably completely subsume the behavioral office. Were this to happen, it would probably be a noteworthy advance in for-profit collaborative care, but it is an example of the technology tail wagging the dog.

5) Need for quality standards. EMRs have been around long enough that medically-focused standards and comparisons are available. For example, AAFP's Family Practice Management journal will regularly produce a readership survey that compares user satisfaction along several criteria, including: ease of use for basic EMR functions, inter-operability, scalability, cost, technical support, etc. Similarly, professional and governmental organizations have recommended EMR standards that encourage software companies to produce EMRs that better meet user needs. The collaborative care constituency has not yet produced such standards. Perhaps this type of project could be commissioned by Families, Systems, and Health journal. The results could be crafted into a CFHA position statement.

In the absence of such an undertaking, please use the comment space below to add your own thoughts and experiences regarding collaboration in an EMR environment.

How have electronic records helped and hampered collaboration where you live?

Which EMR do you use, what are its strengths, weaknesses, and idiosyncrasies?

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A New Sub-Specialty And The Development Of Its Workforce Via Technology

Posted By Neftali Serrano, Thursday, January 28, 2010
Updated: Friday, June 10, 2011

I started about 4 years ago as the result of the most obvious difficulty I was facing in developing a primary care behavioral health service (PCBH) at a Federally Qualified Health Center (FQHC) in Chicago, IL: I couldn't find anyone to hire on.

Fortunately this was also the time when iTunes and other Mac software were providing a unique opportunity to technology novices like me - the ability to reach large numbers of people with websites, blogs and podcasts. My goal was to, at the very least, contribute to the growing web presence of PCBH and in so doing perhaps stimulate students and early career professionals to consider developing skills in this area. Remember that at the time a search of PCBH related terms yielded a whole lot of nothing - at least not that which was relevant to PCBH and certainly not to the model of care I was working in, Behavioral Health Consultation (with one exception being Dr. Blount's website,

So, even more so today technology must play a role in developing a workforce. As a consultant to clinics in various states I know there are jobs out there - some of which simply need to be created by knocking on the door of the clinic. My current position as director of a PCBH program at an FQHC in Madison, WI started out just that way. There was no job posting - I just knocked on the door and said: "I can do this. Do you want me to do it here?" And 4 years later we have a robust PCBH program with 3 other staff psychologists. The point being that we need to develop workers with skills and predisposition to work in integrated care models. At present most everyone requires retraining.

So, I'm open to ideas. What role can technology play in developing the workforce? I think we're going to have to think outside the box on this one. For example, one of the things I do to train folks is use video-conferencing software to provide training/ supervision. Another is the use of GoogleDocs where trainees in other cities post their SOAP notes and I provide commentary to refine writing and case conceptualization skills. But we have to think scale here, especially with the likely expansion of primary care via the health reform legislation. In about 8+ years in PCBH I've managed to train nearly 40 professionals, but even if all of us did the same we would not meet the need for BHCs.

I would consider the following functions as core to any future technological approaches to training:

  • Facebook-type networking ease
  • A means of rapidly disseminating data from small centers/ clinics to incrementally move evidence-base (think quick and easy form submission)
  • Video/Text education modules from experts that help categorize types of PCBH and identify core components
  • Web-based video-conferencing to rapidly connect professionals in mini-conferences (think Skype, but within the one portal where data from the mini-conferences can be housed and archived)
  • Potential for hosting larger forums for audiences that can check in for a live-stream conference and also interact with presenters
  • PCBH Wikipedia-like article section where contributors refine concepts over time
  • Q&A Forums
  • Marketplace for professionals to shop for more intensive consultation, supervision, books, proprietary PDF downloads, etc.

The basic idea, I think, is to be able to duplicate what we all get at the annual CFHA conference for 365 days of the year, and be able to share data and knowledge in incremental and economically efficient ways. There are hundreds of conversations we all have with each other that others would benefit from and many small projects and data collection efforts that have value, especially in aggregate. If this makes sense to you, I'd love to hear from you. What other ideas do you have?

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Using Technology to Advance Collaborative Care Research

Posted By Ben Miller, Tuesday, January 26, 2010
Updated: Thursday, June 2, 2011

There exists an opportunity to begin to leverage technology in such a way that we can advance collaborative care in ways only imaginable before. Just as the Collaborative Care Research Network (CCRN) has started increasing the effectiveness research for collaborative care practices, new and emerging technology allows for an advancement of research with large data sets consisting of millions of patients and hundreds of practices. This is a "game changer" that our field must take advantage of to begin to make a stronger research case for collaborative care.

A tale of two cities

Technology has changed everything. Never before have we had instant access to so much at one time. Need a new sweater at 3am? Done. Need a new car? Done. We are efficient and we are decisive. Technology means never having to say no to instant access to information. Everything is accessible and on our timeframe.

Wait, did I say everything? I meant everything but healthcare.

Healthcare remains the single largest non-immediately accessible service through technology. Interestingly enough, the last ten years have seen a push to integrate technology and healthcare in new and novel ways. Case in point, to be a patient-centered medical home (according to NCQA), one has to meet certain technology requirements, which include such things as the Availability of Interactive Website, Electronic Patient Identification, and Electronic Care Management Support. Bottom line, technology is important and everyone knows it, including healthcare stakeholders. Primary care has integrated electronic medical (or health) records (EMR) in a way that has changed the way medicine is practiced (hang on to this for a minute). Plus, many like the electronic medical records adoption as it saves money in the long run.

Now, consider the following. Primary care practices range in size and scope. However, electronic medical records are becoming pretty common in many medical settings. And, there is no shortage of different electronic medical records. Herein we find a small problem. If, different practices use different electronic medical records, how can we look across practices for themes, etc.? As many practice-based research networks do, common questions are asked to different practices and data is aggregated to answer the research question. This information was collected through chart reviews, card studies, etc. Does this change when we begin discussing electronic medical records? Possibly not if all practices used the same electronic medical record; however, practices are as uniquely enrolled in electronic medical records as they are in patient demographic. So, even if we wanted to examine across site research questions using technology and EMRs could we?

Enter DARTNet. The Distributed Ambulatory Research and Therapeutics Network or DARTNet is a federated network of different practice with different EMRs. DARTNet combines data from different EMRs to create a large database (think over 4 million patient lives) capable of answering almost any question one could ask with data from an EMR. Did I mention this was a game changer? Now, please click over to this cow and chicken picture as you visualize and think COLLABORATIVE CARE.

Yes, the connection I am attempting to make has to do with mental health/primary care and EMRs. You see, anytime we talk about collaborative care, there is the obligatory mention of the incompatibility of mental health imbedded in primary care and using medical records. Not so real life quote, but close: "The HIPAA police will arrest me". There does appear to be some issues here, which can be written about on another post so I will leave it at this: to truly examine collaborative care, our field is going to need to find a way to evaluate many of our core field specific assumptions in tandem with technology.

It may be more helpful for this post if I use a metaphor:

When you are in an art gallery and see a unique piece of art, the last thing you likely want someone to do is to come up to you and say: "this is what the artist meant when he created this piece..." You don't necessarily need interpretation of a specific piece as part of the beauty of art is your interpretation of the piece. DARTNet, technology, collaborative care, research it is all the same thing. I can tell you what could come from such relationships but would that really be what is best for you and "the piece?" I would encourage each of you to read the following article:

Pace, W. D., Cifuentes, M., Valuck, R. J., Staton, E. W., Brandt, E. C., & West, D. R. (2009). An Electronic Practice-Based Network for Observational Comparative Effectiveness Research. Annals of Internal Medicine, 151(5), 338-340.

For collaborative care to grow, technology is something we must grasp. To this end, without taking advantage of technology and research simultaneously are we relegated to the sidelines? I refuse to sit by and watch while everyone else has fun and makes a difference along the way - you?

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What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.