Specialists

Specialists have unique electronic health record (EHR) needs for clinical documentation and care coordination with other specialties, subspecialties, primary care, and other care settings.

Historically, very few specialists have adopted EHRs, but that’s changing with the advent of specialty templates and modules optimized for specific specialties, such as ophthalmology and dermatology. EHR options for multi-specialty groups are also evolving and gaining adoption in certain specialties.

This section provides EHR and health information exchange guidance for specialists.

It also offers:

• Workflow tools
• Case studies
• Best practices

The behavioral health system provides treatment and services to care for individuals’ behavioral health, substance use disorders, and mental disorders. A significant number of people rely on this system:

• An estimated 26% of Americans age 18 and older are living with a mental health disorder in any given year, and 46% will have a mental health disorder over the course of their lifetime
• According to the National Survey on Drug Use and Health (NSDUH), 24.6 million Americans reported current use of illicit substances and another 17 million reported using alcohol heavily over the past month
• Approximately 40% of adults with "severe" mental illness — such as schizophrenia or bipolar disorder — received no treatment in the previous year and 60% of adults with any mental illness did not receive treatment
• More than 80% of the individuals who met criteria for substance use treatment did not receive treatment
• Individuals with serious mental illness (SMI) and substance use disorders (SUD) tend to have higher rates of chronic physical health conditions than individuals without a behavioral health disorder

Improving timely access to health information can improve care, but there are significant challenges related to health IT for behavioral health clinicians. Adoption of health IT in behavioral healthcare is significantly lower than other specialties. Reasons for this may include (but are not limited to):

• A lack of interoperable information systems
• A lack of resources to invest in and maintain health IT systems
• Limited expertise of health IT systems
• Reluctance by clinicians to engage in the exchange of behavioral health data
• The complexity of privacy laws and the effort it takes to manage data disclosure consent requirements
• Ineligibility for EHR incentive programs

How health IT can support behavioral health

Several types of technology support behavioral healthcare, including telebehavioral health (discussed further below), care management and care coordination platforms, and health IT functionalities. Health IT capabilities that serve critical roles for behavioral health include (but are not limited to):

• Data segmentation: the tools to sequester from capture, access, or view certain data elements that are perceived by a legal entity, institution, organization, or individual as being undesirable to share¹
• Privacy management: technologies and best practices that protect individuals’ privacy, including de-identification and encryption of data, restrictive access to protected health information, and security measures in underlying technical platforms²
• Medication management: capabilities that provide oversight on potential adverse medication side effects and medication non-adherence tracking³
• Practice, treatment, and therapy modules: technology-based assessment and intervention tools that supplement existing care methods and services⁴
• System access controls: capabilities to manage access rights for systems and controls to ensure the relevant personnel have appropriate data access⁵
• Audit logs: security audits using audit logs and trails to record key activities and detect discrepancies⁶
• Clinical decision support (CDS): tools and behavioral health screenings to assist clinicians with potential intervention and treatment⁷
• Communication tools: tools, such as secure email, that allow clinicians and individuals to send and receive sensitive health information

Refer to the Health IT Playbook’s Certified Health IT section for more information on the role and benefits of certified health IT functionality and capabilities. Refer to the Privacy and Security section for information on privacy and security standards; permitted access, uses and disclosures of health data; preparing for audits; and tips for cybersecurity.

Behavioral health patient engagement

Recent studies have determined that behavioral health service integration produces greater engagement in care and, in turn, drives more favorable outcomes.^{8, 9, 10, 11}

For example, documenting and following individuals’ preferences, promoting active and informed participation tailored to their abilities, attending to their emotional needs, and supporting their autonomy can establish rapport and increases the likelihood that they will engage in treatment. Strategies including education, communication, and shared decision-making approaches can generate positive health outcomes.

Just as for physical health, patient engagement and activation for behavioral health begins at the reception desk and continues through the course of the clinician visit. Training the practice team to show empathy and compassion when interacting with individuals seeking behavioral health services is a vital part of delivering person-centered care. Including individuals’ perspectives by facilitating patient advisory groups on how to improve healthcare services and policy also provides the opportunity for engagement, education, and progress.^{12, 13}

The consent management process should be tailored to the needs and abilities of individuals seeking behavioral health services, and it should include education about rights and tracking consent across clinicians.¹⁴ Consent must be decided on by the individual with full knowledge of the risks and benefits of sharing or withholding information. Consent management simplification, such as a standard consent form and electronic signatures, can streamline the process, minimize burden, and promote trust.¹⁵

Refer to the Playbook’s Patient Engagement section for fact sheets, research briefs, strategies, and up-to-date information on initiatives and trends for patient engagement.

Privacy regulations related to behavioral health

As primary care is often the gateway for individuals to address their behavioral health needs through their primary care clinician (PCP) and, as a result, more PCPs are offering integrated behavioral healthcare services. This presents unique health information exchange challenges due to confidentiality rules surrounding sensitive health information.

Behavioral health information — such as psychotherapy notes, substance abuse treatment records, and psychiatric diagnoses — legally qualifies as sensitive health information. In addition to federal regulations, individual states may have specific laws for disclosing or exchanging sensitive information.

EHRs and health information exchange solutions are evolving in their ability to best capture and segment sensitive health information to facilitate use of health IT to better manage and coordinate care.

To protect behavioral health information, it is important to understand the federal and state laws that govern the privacy of health information.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

• HIPAA establishes a floor (minimum) of safeguards to protect privacy of “protected health information” (PHI) and establishes patient rights
• HIPAA generally does not prohibit the use and disclosure of mental health or any other specific clinical category of information — but psychotherapy notes and correction medical records are exceptions to this
• Disclosable data includes labs, prescriptions, appointments, and procedures related to mental healthcare

42 CFR Part 2 (Confidentiality of Substance Use Disorder Patient Records)

• This federal law governs confidentiality for people seeking treatment for substance use disorders from federally assisted programs

State health information privacy and consent laws and policies vary widely across the U.S., and may impose additional requirements. Learn more about state health IT privacy and consent laws and policies [PDF – 442 KB].

Refer to the Playbook’s Privacy and Security section for tools, resources, references, and information on protecting the confidentiality, integrity, and availability of medical information.

Behavioral health information exchange (HIE) expands access to health information necessary for comprehensive patient care, but requires adherence to the laws referenced above as well as additional considerations for consent management and establishing patient and clinician trust.

Refer to the Playbook’s Health Information Exchange section for tools and information on secure HIE, learning guides, and case studies for HIE in behavioral health.

Telebehavioral health

As telebehavioral health — or the use of telehealth to support behavioral health services — accelerates, health IT tools can integrate these technologies into care delivery systems and workflows.¹⁶

Recent studies demonstrate the positive health effect and benefits provided by virtual counseling, including convenience, privacy, fewer missed appointments, increased access and choice, and customizable care.^{17, 18, 19, 20} Moreover, with a shortage of primary care and specialty behavioral healthcare clinicians,^{21, 22} telebehavioral health can link individuals in areas with staffing shortages or mobility limitations to clinicians in other geographic areas. Virtual behavioral health sessions provide control over privacy and can reduce stigmatization when receiving care at home or another convenient location.

Telebehavioral health involves specialized technologies, software, and devices. Integrating telemedicine and telehealth services requires a critical understanding of regulatory and legal bounds, licensure requirements, and privacy and security standards.

Refer to the Playbook’s Telehealth section for resource links to national organizations and agencies including CMS, ONC, AHRQ, Center for Connected Health Policy (CCHP), the American Telemedicine Association, and the Telehealth Resource Center.

ONC partner resources

The Office of the National Coordinator (ONC) works with various federal agencies to support behavioral health IT. This section provides resources to support adoption of health IT and care coordination in behavioral health. For example:

• ONC partners with SAMHSA to promote the development, dissemination, and effective use of health IT to support prevention, treatment, and recovery
• The Agency for Healthcare Research and Quality (AHRQ) created the Academy for Integrating Behavioral Health and Primary Care resources to support behavioral health integration, including products, insight, and a community platform

Pediatric healthcare includes both primary and subspecialty care for children. Care for the pediatric population largely happens in ambulatory care and inpatient hospital settings. Challenges may arise with functionality, documentation, and privacy when implementing and using health IT in pediatric care.

For example, documentation needs when caring for children include:

• Growth charts
• Weight- and age-based dosing
• Clear indication of smaller units of measure
• Pediatric normal ranges for vitals, labs, and other measurements
• Parent-baby documentation
• Gestational age and corrected age (or adjusted age) used in calculations

Healthcare facilities also encounter specific privacy requirements around parental involvement in healthcare and consent for teens — or for custodial, foster, guardian, or adoptive care.

To optimize care for pediatric patients, healthcare providers and health IT developers can work together to support the needs of their practice setting. The Office of the National Coordinator for Health Information Technology (ONC) has developed 2 informational resources (IRs) intended to support implementation and use of health IT products in pediatric care: the Pediatric Health Information Technology Healthcare Provider IR (Healthcare Provider IR) [PDF - 924 KB] and the Pediatric Health Information Technology Developer IR (Developer IR) [PDF - 535 KB].

The Developer and Healthcare Provider IRs identify ONC’s 10 health IT recommendations for pediatric care and provide other information to support implementation of health IT in pediatric care. These 10 recommendations are informed by the clinical priorities of the American Academy of Pediatrics (AAP) and build on federal and stakeholder activities to date, including efforts supported by the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS).

The Healthcare Provider IR is intended to help healthcare providers work with health IT developers to implement these recommendations. Below you’ll learn more about each recommendation — including certification criteria supporting the recommendations, suggested questions for discussion with your health IT developer, and further reading.

Recommendations for Health IT for Pediatric Care

ONC Recommendations for Pediatric Health IT Voluntary Certification Criteria

Recommendation 1: Use biometric-specific norms for growth curves and support growth charts for children. This recommendation supports the accurate assessment and characterization of growth by encouraging health IT systems to incorporate visual displays of growth charts. These charts plot selected growth parameters — such as height, weight, head circumference, and body mass index (BMI) percentiles over time on standardized Centers for Disease Control and Prevention (CDC)/World Health Organization (WHO) growth curves as appropriate.

Recommendation 2: Compute weight-based drug dosage. Accurate and recently recorded height/length and weight is a key input to medication dose calculation for pediatric patients when the dose varies based on these factors.

Recommendation 3: Ability to document all guardians and caregivers. Due to the unique caregiver and guardianship scenarios for pediatric patients, maintaining an accurate and structured record of a patient’s care team is a critical component of an electronic health record (EHR) supporting pediatric patients. The care team may include caregivers and guardians such as biological parents, foster parents, adoptive parents, surrogates, custodians, siblings, or case workers.

Recommendation 4: Segmented access to information. This recommendation addresses the need for privacy of certain services by tagging electronic health information and providing or limiting electronic access to certain segments of the record to specific users.

Recommendation 5: Synchronize immunization histories with registries. This recommendation supports up-to-date bidirectional pediatric immunization information for healthcare providers by encouraging health IT systems to support, update, and reconcile a child’s immunization record with information received from Immunization Information Systems (IIS).

Recommendation 6: Age- and weight-specific single-dose range checking. The implementation of this recommendation allows the system to alert if the maximum recommended adult or pediatric dose of a medication (based on weight or body surface area dose for a single dose or for a total daily dose of the medication) is exceeded.

Recommendation 7: Transferable access authority. The care team members allowed to access a pediatric patient’s health record may change over time due to changing family dynamics (e.g., foster care, adoption, and divorce). This recommendation manages access authority and changing circumstances of pediatric patients.

Recommendation 8: Associate maternal health information and demographics with newborn. This recommendation supports clinicians by allowing access, at the point of decision-making, to maternal information needed for the care of the infant. It ensures that healthcare providers don’t need to hand copy information over from one chart to the infant’s chart, decreasing risk of error and making the process more efficient.

Recommendation 9: Track incomplete preventative care opportunities. This recommendation addresses the need to alert healthcare providers when a child presenting at a visit has not received or is due for preventive care services. This recommendation leverages an EHR’s ability to detect clinical criteria and the absence of events such as well-child visits or age-appropriate screenings.

Recommendation 10: Flag special healthcare needs. Children with special healthcare needs are defined as at increased risk for chronic physical, developmental, behavioral, or emotional conditions — or as requiring health or health-related services of a type and amount beyond that required generally. Healthcare providers can easily flag individuals whose care may benefit from specific decision support, care management, or other focused attention.

The Developer and Healthcare Provider IRs don’t offer specific workflows or comprehensive solutions for healthcare providers — rather, they’re intended as first steps. Healthcare providers may wish to prioritize specific recommendations in practice based on the needs of their particular care setting.

Online Resources for Pediatric Care

The Healthcare Provider IR [PDF - 924 KB] outlines many resources with information about implementing health IT in support of the care of children.

Check out the following helpful resources from AAP:

• The AAP Patient Care topic page offers information about topics across the spectrum of pediatric care
• AAP’s site for parents, healthychildren.org, features educational resources for parents with children of all ages
• The AAP Health Information Technology topic page provides information about selecting an EHR, the Promoting Interoperability Programs, patient portals, and more

For future updates on using health IT to support the safe and effective healthcare of children, visit ONC’s information on Health IT for Pediatric Care.