Hospital SUD Programs, Psychiatric Hospitals Lag in Electronic Health Record Use

Hospital-based substance use disorder (SUD) programs and psychiatric hospitals are less likely than acute care hospitals to use basic electronic health record (EHR) and electronic health information exchange (HIE) technology, a study in Psychiatric Services in Advance has found.

Morgan C. Shields, Ph.D., a National Institute of Mental Health postdoctoral fellow in the Center for Mental Health in the Department of Psychiatry at the University of Pennsylvania, and colleagues reviewed data from the 2017 National Survey on Substance Abuse Treatment Services to determine the extent to which basic EHR functionality has been adopted by hospital-based SUD programs. They defined basic EHR functionality as assessment, progress monitoring, discharge, labs, and prescription dispensing. The researchers also analyzed the use of electronic HIE across hospital-based SUD programs.

In 2017, 68% of hospital-based SUD programs reported basic EHR functionality compared with 84% of acute care hospitals, and 71% reported sending electronic HIE to outside health care professionals, compared with 88% of acute care hospitals. Psychiatric hospitals were roughly half as likely as acute care hospitals to have adopted EHRs. Hospitals that used HIE to send information to outside health care professionals were nearly five times as likely to use basic EHR functionality.

“This study demonstrates disparities in the use of basic EHR and HIE uptake, which is a small part of a much larger phenomenon of health policies sidelining behavioral health innovation and quality improvement efforts,” Shields told Psychiatric News. She added that the results are in line with a previous study the researchers published in the June 2020 issue of Health Affairs that found that 88% of acute care hospitals used electronic HIE when transferring patients to outside care, but just over 56% of psychiatric units within those hospitals did so.

Barriers to Adoption

In the current study, the researchers noted several potential reasons for lower EHR adoption among hospital-based SUD programs and psychiatric hospitals, including the stringent privacy requirements of 42 CFR Part 2 and of various state laws.

“While there are different nuanced caveats depending on the situation, in general the primary additional requirement imposed by 42 CFR Part 2 is that that federally assisted SUD programs must obtain written consent from patients before sharing information about their SUD treatment, diagnosis, or history to another provider,” Shields explained. “This has the effect of potentially hampering care coordination, and some SUD programs might create their own structures and processes for information storage outside of the EHR platform used by their overarching health care organizations.”

Shields added that freestanding psychiatric hospitals—hospitals where psychiatric care delivery does not take place within larger acute care hospitals—were excluded from the Health Information Technology for Economic and Clinical Health (HITECH) Act, a federal incentive program that was intended to promote adoption of health information technology.

“The HITECH Act greatly accelerated uptake of health information technology in general in acute hospitals, but left psychiatric hospitals on the sidelines,” she said.

In the study, hospital-based SUD programs that provided medications for alcohol or opioid use disorders were nearly twice as likely to use basic EHR than those that did not provide such medications. This may be a reflection of the acceptance of medication treatment for SUD, said addiction psychiatrist Petros Levounis, M.D., M.A., chair of psychiatry at Rutgers New Jersey Medical School, who was not involved in the research.

“A lot of substance use treatment programs have not fully adopted the use of medication treatment, and when you offer fewer medications, it makes sense that you are less likely to use EHRs,” he said.

Levounis added that some SUD treatment programs feel that because they do not use many laboratory tests, imaging studies, or other forms of assessment that are usually maintained in an EHR, there is no need for an EHR system—an approach that he feels is shortsighted.

“People with substance use disorders often have medical and psychiatric comorbidities, there may be drug-drug interactions in the treatment of these comorbidities, and some medications may contribute to metabolic syndrome and therefore need to be followed up with labs,” he said.

Not having an EHR system is risky, Levounis said.

“Places that do not have EHRs still have to send out information on their patients, so they scan the information and send it as a PDF,” he said. He added that few health care professionals write admissions and progress notes by hand. “They use Word documents, and Word documents live in someone’s desktop or memory stick, with all the associated safety risks. You’re not gaining that much confidentiality by not having an EHR system.”

Creating Incentive

Shields noted several strategies that could prompt more psychiatric hospitals and hospital-based SUD treatment programs to adopt the use of EHRs and electronic HIE.

“One step would be for the CMS Innovation Center to test incentive programs specifically targeting behavioral health providers, both hospital based as well as outpatient based, and to include freestanding psychiatric hospitals in these demonstrations,” Shields said.

“To the extent that privacy concerns, or 42 CFR Part 2 in particular, are preventing adoption, more could be done to clarify the implications of these regulations to providers and to provide technical support to providers in ways that appropriately address their concerns,” she added.

Levounis said that strategies for promoting electronic HIE adoption should focus on demonstrating the practicality of using the technology.

“A lot of care coordination is done over the phone. You call, you get put on hold, you leave messages, someone calls you back when you’re not available—it’s an absolute mess. But HIE could save a lot of time and the information will likely be much more accurate,” Levounis explained.

He added that EHR systems and electronic HIE are vital to avoiding disruptions in care in times of crisis such as the ongoing strain of the COVID-19 pandemic and the aftermath of disasters like 9/11, Hurricane Katrina, and Hurricane Sandy.

“These events can paralyze substance use treatment, and patients absolutely depend on some kind of information exchange to continue their methadone or buprenorphine treatment,” Levounis said. “If we are going to brace for [future events], we must have some kind of EHR to support patients.”

The Psychiatric Services and Health Affairs studies were funded in part by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. The study published in Psychiatric Services was also funded in part by the National Institute of Mental Health. The study published in Health Affairs was supported by McLean Hospital and the Health Services Research Division of Partners Psychiatry and Mental Health in Boston. ■