DISCLAIMER: This piece has turned into something of a lengthy retrospective focused primarily on the evolution of various laws and regulations that affect mental health care and as such, may not satisfy your particular curiosity. Feel free to skim if you'd like, where you'd like, and to ask questions about the areas and issues that are important to you. My opinions are entirely my own and my hope is that this piece will nevertheless generate more robust discussion, perhaps leading to other, more comprehensive pieces if warranted, and that you'll read it all anyway, but it will probably take a long time--you might want to get some snacks.
I.
According to Wikipedia, deinstitutionalization in the United States began in earnest in the 1950s thanks to a combination of increasing social awareness of overcrowding, poor living conditions for the mentally ill and the like, the high cost to society of incarcerating the mentally ill, and the promise of new antipsychotic medications. On a side note, one of my coworkers had been a nurse at the time the first wave of antipsychotics came into wide usage at the mental hospitals of the mid-twentieth century and she informed me that the arrival of these medicines was widely known as "when the screaming stopped" to those in the field at the time. To further the process, the Community Mental Health Act was passed in 1963 to establish grants for states to build local community health centers under the overview of the National Institute of Mental Health. It was believed at the time that it was better, when possible, for the mentally ill to both live and receive treatment in their local communities and perhaps serve as fully functional members of society. Meanwhile, landmark lawsuits were being pursued, some of them by the ACLU, that would further alter the legal landscape pertaining to mental illness, culminating in O'Connor V. Donaldson, the landmark 1975 Supreme Court ruling that held that an individual could not be incarcerated against their will unless they were in imminent danger of harming themselves or others or could not care for themselves. The decision was unanimous.
I can't help but wonder if Stewart, Burger, Marshall, Douglas, White, Brennan, Powell, and Rehnquist understood or appreciated at the time the extent to which their ruling would transform issues of mental heath and institutional mistreatment into issues of law enforcement and homelessness.
It is 1999 and I have been hired as a computer technician by my local community service center. I have no idea what my employer actually does, but the answer is that we provide access to psychiatrists, case management services for the mentally ill and developmentally disabled, group therapy for substance abuse, screenings for those who might potentially require involuntary hospitalization, a parent-infant education program, two psychosocial day centers at the north and south ends of our territory, and additionally run three separate inpatient programs--one for children, one for adults, and one specifically to help patients discharged from state mental hospitals to live in a group setting and, if possible, transition to living independently. We serve several counties and one city.
My employer was founded in the early seventies and is funded mostly with Federal dollars through a combination of Community Service Block Grants, funneled through a state department specifically for the mentally ill,the developmentally disabled and those with substance use issues, Medicare and Medicaid dollars which are funneled through another state department, and (a small amount of) local tax dollars from the city and the various counties that we serve. Moreover, the Mental Health Parity Act has recently been signed into law, requiring insurance to cover mental health treatment at the same level of funding that the cover physical health treatment. Other localities differ in their services offered by virtue of receiving more/better local funding for their particular community service center. Our funding, by comparison, has always been lacking.
I don't know this at the time but despite our poor level of funding, these are the salad days four our mental health center and I have arrived just in time to witness them. Our various clinics seem to be run well and we provide a variety of services to our area, though they tend to be on the basic side aside from those that are funded by specific grants. Deinstitutionalization is still a big Thing and our state run mental hospitals are still working to discharge folks that are deemed to be no danger to themselves.
Of course, all is not sunshine and roses. Water cooler gossip is an easy vice and can range from the mostly harmless amusement at a particular client's peccadilloes (such as the client with the delusion that Jesus was a member of Kool and the Gang) to more busybody-like criticism and denigration. We have staff that get too directive, too aggressive, and too involved in the lives of their clients. HIPAA security rules are (presumably) still being written and argued over and for all practical purposes our client records are protected solely by the honor system with no checks and balances in place to protect client confidentiality. Most of the staff I interact with, however, are pleasant kindhearted, and earnest in their performance of their jobs.
Everything seems to be running smoothly at first. So smoothly, in fact, that the executive director resigns because he feels he has nothing major left to do or build. Soon afterwards, the dot com bubble pops and the economy tanks. In reaction, our funding is cut severely and even taken back in the midst of the current fiscal year. Salaries are frozen and layoffs are imminent. Funding and grants for many programs dry up, forcing us to close them. Throughout my tenure here, this pattern will cyclically repeat itself.
II.
It almost goes without saying that there is plenty of controversy surrounding pyschiatry specifically and the concepts of mental health and mental illness in general. One of these is the use of the medical model of mental illness, which is essentially the belief that mental illness and mental disorders are rooted in biological issues. The overwhelming success of the first wave of antipsychotics and the clear successes of the second wave of antidepressants has greatly bolstered this model of treatment. Accordingly, we are tasked with reporting many things that focus on behavioral and social issues by the department that controls the block grant funding, while also reporting the required medically focused data to the department of Medicare and Medicaid as we bill for our services. In fact, we are considered healthcare providers from a legal perspective and are bound by all relevant laws and regulations pertaining to the healthcare industry.
It is 2003 and I have been promoted from computer technician to MIS (Medical Information Systems) Specialist and we have hired another person into my old position. In the wake of the earlier fiscal shock, our new Executive Director is emphasizing running our service organization more like a business. Things are changing! Even now it is obvious that we will need more in the near future; HIPAA has mandated the move to EDI (Electronic Data Interchange) code sets and rules, which are a twisty maze of specifications and regulations which I would encourage you to peek at in the link just to get a feel for the complexity--the relevant parts are under the "transactions and code sets rule" in Title II. Fortunately for us, our medical practice based software, a sturdy old RPG based platform running on Unix, has been bought by $Big_Online_Company and is a planned centerpiece of their entry into the new world of EDIs and Electronic Medical Records (EMR). Implementing this will be a huge task and will involve things like deploying a wireless network, a fleet of powerful SCSI-based scanners to convert paper records into electronic records, almost tripling our PC inventory as each clinician will now be using Word to write electronic notes, etc.
On the clinical side, we are recovering from the rescinded funds of the dot com bust. Our only remaining residential program is the long-term inpatient group home for those discharged from state mental hospitals, though that is still going strong. Deinstitutionalization in general is about to wind down as the state reaches its target bed numbers but is still a Thing for the moment, and discharge assistance funds are still available. Some good people have left, and in some cases have been replaced by some not-as-good people and the clinics in question have suffered as support for clients and clinical staff has worsened. Time passes.
It is 2005 and my boss is making a presentation on the triumphs and challenges of implementing an EMR at a statewide conference on the bright new future of healthcare technology. Our experience has been a mixed bag at best, to put it kindly, and has taught us many lessons. Staff had a high level of uncertainty about using an entirely electronic system and likewise, a high level of resistance to changing the way they work. Some clinicians have been able to adopt to using PCs to do their work while others can not or will not adapt well to using a PC. Some staff quit outright, while others in the latter category remain and generally become a burden to support staff in general and our department specifically. Converting existing paper records to scanned records is an ongoing and tedious process, and has the benefit of being accessible by anyone but also can be harder to read, especially when the material is handwritten. Mistakes are still made in the electronic record but can sometimes be harder to correct due to the stringency of some rules and regulations surrounding the editing of data and notes. It is, however, easier for mistakes to be caught by reviews and compliance given the increased accessibility to all charts. It is also easier for staff to violate the privacy of clients by viewing client data that they shouldn't be viewing and in our particular case would require strong oversight and enforcement from compliance with the backing of upper management in order for us to maintain reasonable safeguards. Ultimately, it has made some things easier and some things harder, but overall it has definitely created a heavier burden for our entire organization, by at least an order of magnitude, than the old paper system that preceded it.
Aside from our presentation, however, most of the conference is abuzz about the positive impact that technology can and will have on healthcare in the future. Health Information Exchanges (HIE) will soon allow us to exchange client information with each other through the magic of a standardized data format, HL7! Federal funding will assist us with building and accessing this bright new future for healthcare! Other presentations from statewide efforts to share data with medicaid departments in other states are more positive than our own experience! Speaking of data, a statewide initiative to consolidate and standardize disparate data requests and requirements into a single, unified set of sixty to eighty-odd data elements is underway. The paper surveys that I initially collated as a bored junior staff member have mushroomed, often into Excel spreadsheets, and have become burdensome and difficult to complete in a timely fashion and it is hoped that a common data set will satisfy future requirements and alleviate some of the survey burden.
Moloch has entered the chat.
III.
The American Recovery and Reinvestment Act (ARRA, aka the Stimulus) has been passed. Because EMRs have been found to be costly, inefficient, and relatively user-unfriendly, the Health Information Technology for Clinical Heath Act (HITECH), enacted under Title XIII of the ARRA, provides funding for the healthcare industry at large to adopt systems that provide adoption of an Electronic Health Record (EHR-if you're wondering what the difference is between an EMR and an EHR, you're not alone). Additionally, it provides additional funds over the course of several years if doctors can meet the standard of Meaningful Use. Conversely, adopters of an EHR whose doctors do not demonstrate meaningful use will be docked a small but increasing amount of Medicare funds.
It is 2010 and I am attending another data conference. My boss has sent me here specifically to attend a presentation from another service center on the triumphs and challenges of moving on from their ancient database and implementing a modern EHR-based system. It turns out that staff had a high level of uncertainty about using an entirely electronic system and likewise, a high level of resistance to changing the way they worked. Some clinicians were able to adopt to using PCs to do their work while others could not or would not adapt well to using a PC. Some staff quit outright, while others in the latter category remained and generally became a burden to support staff in general and our department specifically. The presenter and implementation lead suffered a heart attack in the course of the implementation, in no small part due to his overall stress levels as project lead. Ultimately, it has made some things easier and some things harder, but overall it has definitely created a heavier burden for their entire organization, by at least and order of magnitude, as opposed to the old paper system that preceded it. It is all familiar to me and I strongly suspect that I was sent at least partly to gloat commiserate about the common difficulties of modernizing.
Despite being further down this path ourselves, dealing with our administrative burden is beginning to be a struggle. Medicaid regulations have begun to inexorably creep into our documentation requirements and to make matters worse, are often overlapping given the variety of services that we provide, contributing to staff confusion and clerical errors. The initial sixty-odd data elements that were standardized are growing quickly and are poorly understood by staff, and I am tasked with tidying up the data that we send on a monthly basis to minimize rejections. I frequently and shockingly encounter pushback from even supervisory level staff on things like the proper Axis for a diagnosis, how to classify drug diagnoses, and the difference in terms of art like Serious Emotional Disturbance and Serious Mental Illness, which in point of fact is a strictly age-based distinction. At this point, it is crystal clear to me that the majority of behavioral staff are terrible with concrete definitions and categories and that they are generally a poor fit for such precise data gathering. Worse still, the standard data set has not seemed to stem the tide of surveys that we are required to answer, often with short turnaround times, and in point of fact, said surveys often request data that we don't necessarily collect at all.
Client care suffers as staff are spending ever-increasing amounts of time doing documentation to meet the increased regulatory burdens. Despite trying to run our centers as a business, our funding has remained relatively stagnant. The populations of our counties and city, on the other hand, have continued to grow, also increasing our workload. Two of the counties we serve now qualify as suburbs! Another program has closed and worse still, an unhealthy us vs. them mentality has become pervasive throughout our organization. Staff are largely ignorant of the state and federal level legal and regulatory requirements that have led to the current administrative and staff burden, seeing this instead as the fault of our administrators. Lines have been drawn, leadership has clashed, and the losers either resign outright or engage in quiet quitting, pushing their unofficial support burdens to surrounding staff. Unofficial support itself is a huge burden as new staff are regularly hired with little or no technical skills and thus have to learn how to use Windows and Word and how to navigate our particular system on the fly, and most of this burden falls to the clerical staff that have used it since my time here, and the three of us in IT/MIS. We are accruing technical debt at an alarming pace. Things are strained to say the least.
The cherry on top of this unfortunate situation is that our medical practice system has ceased being developed. $Big_Online_Company, perhaps recognizing the size of the field they were playing on, divested themselves of our software and sold it to a $Solid_established_software_company that while good at supporting the existing codebase, has made minimal to no effort to fix bugs, release updates that address glitches and incompatibilities, and otherwise keep the software current, frequently requiring us to implement workarounds and/or stay on older versions of software in order to keep things running. And while $Big_Online_Company did develop a newer, more modern front end for their system, it's still the same old RPG-based code on the back end with all of its inherent limitations, and although it would technically meet the HITECH requirements, it would be an obvious disaster for us to implement absent a large and customized set of code designed just for us.
IV.
In August 2008, HHS proposed moving from ICD-9 diagnosis codes, which are used for billing purposes, to more modern ICD-10-CM codes. The new ICD codes were originally to be put in place by October 2013, then delayed to October 2014, and finally to October 2015. On the clinical side, the DSM-5 is released in 2015, which is an update to the DSM-IV-TR and changes many things and thus is an ongoing source of controversy.
It is 2013 and we have gone through a grueling Request For Proposal (RFP) process to replace our now long in the tooth medical practice system. Our three choices are the aforementioned update to our existing medical practice software based on ancient and hoary RPG, an old and crusty behavioral based system based on old, outdated, and niche Delphi, of all things, and a comparatively modern, web based behavioral system running on .asp and SQL and increasingly being adopted by other service centers around the state. The choice is an obvious one and we are now implementing the web based behavioral system. Staff have a high level of uncertainty about using a new web-based system and likewise, a high level of resistance to changing the way they work. Some workflows require significant change while others will be eliminated entirely. Some staff will quit outright, while others will remain, digging in their heels, and generally become a burden to support staff in general and our department specifically. Overall, however, the new system is more forgiving of mistakes and much more user-friendly than the previous and ultimately, it will make many things easier and only a few things harder. It will, unfortunately, require a much higher level of coordination between the various programs and clinical centers and administrative and MIS/IT staff in order to run smoothly. But wait! There's more! We have decided to demonstrate Meaningful Use with our new EHR, which is a twisty maze of specifications and medical codes that I would encourage you to peek at in the link just to get a feel for the complexity of meeting its requirements. Because I have become the de facto owner of our electronic forms, I am tasked with working with C-level staff in order to develop the required workflows and insert the required documentation into the required places.
Administrative burden continues to increase, as does our technical debt. Our CEO has resigned and a new CEO is incoming, with a desire to place more emphasis on expanding the services that we provide to the community through increased commitments from the various localities and grants and other forms of federal and state funding for various services. Things are changing! Worse still, our state has decided to outsource Medicaid billing to a private insurance company, a move which also will significantly increase our administrative burden. Our once manageable data set that we regularly report is pushing 100 individual client data elements, and in fact we are now reporting ever-more data to ever-more acronyms relevant to various state and federal initiatives in ever-more ways--there are 16 more initiatives requiring their own data, in fact, as counted by our statewide data committee.
Implementation progresses. There are many pain points, most of which are technical in nature and difficult for clinical staff to understand. In our new system. There is much concern for minimizing staff disruptions and minimizing change to workflow wherever possible. As a result, many potential gains are left unrealized. Despite all of this, and due in large part to extended hours worked by the staff involved in implementation, our roll-out is fairly smooth, and most of our major issues are ironed out within the first two days of going live.
Unfortunately, client care still suffers as staff are still spending ever-increasing amounts of time on documentation to meet the increased regulatory burdens. Substance use services are a vestigial remnant of their former selves, and we have dwindled to one staff member responsible for the whole of them, which mostly involves with facilitating inpatient treatment for clients. Worse still, our developmental disability data is lacking as a state, and we have been found negligent in discharge of our duties, resulting in a meticulous and vastly increased amount of paperwork and data reporting, some of which has been helpfully added in by the department of developmental disability itself in a prime example of friendly fire via lawsuit. This is further exacerbated when the developmental disability department funds a state website to authorize treatment for the developmentally disabled and to enter client treatment plans electronically, potentially leading to double entry as all state entities serving the developmentally disabled must send this data to the department. Additionally, the department signs a contract with a leading IT vendor to develop interoperability between their brand new website and the existing EHR systems that various state centers and agencies are using. The specifications are agreed upon, the contract is finalized, and the department promptly violates the contract and invokes financial penalties two weeks later when they change the data specifications. This will not be the last time that this happens before the interoperability project is completed. Time passes.
It is 2016 and my boss and I are attending a workshop about Government Reporting Modernization Act (GPRA) reporting that we must do as a part of our award of State Opioid Recovery (SOR) funding. It is entirely how-to and a complete waste of our time, and also exemplary of the growing expectation that we will administer anything and everything related to clinical functions. GPRAs have several flavors the flavor we use is detailed and invasive in its questions, as it involves substance use and sexual habits. As part of our SOR grant for Medication Assisted Treatment (MAT) for opioid use, we are expected to administer the GPRA to all incoming clients that are receiving MAT and to follow up with them periodically for two years after termination of services if possible. We bail on the second half of the presentation.
We are beginning to drown in a sea of unintelligible data, administrative burden and technical debt. It is so unintelligible, in fact, that even at the state level they are consulting with their foremost auditor, who had retired, to help them understand their own data requirements. Documentation is now for all intents and purposes a full-time job in and of itself and, just like their pure healthcare based counterparts, staff are compensating either by skimping on their documentation or by working unreported overtime. Developmental disability continues to be a rolling train wreck of continuous updates to data and documentation requirements and non-functioning interoperability between their website and the various EHRs; most service centers including our own have abandoned all attempts to use their own EHRs to document the individual service plans and use the state website exclusively and then simply attaching a copy of that documentation to a service or record in their respective EHR platforms.
Worse still, our state has decided that outsourcing Medicare and Medicaid reimbursement to private insurance has gone so well that they bring in over a dozen new insurance companies! Ostensibly, they all agree to common requirements but in practice this is not so true, leading to large billing and documentation headaches on the back end. Registration and admission forms are frequently changed, requiring increasing amounts of time both to update and understand. I am darkly amused when I find that different insurers are categorizing race and ethnicity, a data point that has mushroomed in the last decade or so, differently than the agreed-upon state standard as well as differently than each other. But wait! There's more! We are now required to do service specific provider intakes, meaning that if a client is enrolled in multiple services, each service must have its own intake and each intake is supposed to be performed by a Licensed Mental Health Professional (LMHP) type, which requires a graduate degree, significant amounts of time as a supervised resident providing services, and the passing of a test. This is a large and unwelcome change as we already have significant issues with hiring and keeping licensed professionals and even residents, as they largely leave for greener and easier to navigate pastures as soon as possible.
V.
The Excellence in Mental Health Act, a part of the Protecting Access to Medicare Act, was passed in 2014 and established a new model for treating mental health and substance use disorders within the community regardless of a client's ability to pay-the Certified Community Behavioral Health Clinic (CCBHC). The intention is to quickly provide clients with access to services regardless of their status and ability to pay.
It is 2018 and our state has passed legislation to implement the CCBHC model within the existing framework of our legislation and regulation. We're going to provide clients with same day access to intake and services! There won't be any more waiting lists! We're going to skip all the paperwork and use a standard assessment tool (which we must pay a fee to license each provider to use, natch) to assess a client's daily level of functioning. Why, there's all kinds of redundancy in data gathering and paperwork, don't you know? (Shut. Up!) We're going to eliminate all of that and just focus on getting clients in the door and into services! Staff can and should document their encounters collaboratively with clients! Better still, we can use more lightly credentialed peers to provide services instead of more expensive licensed staff!
The consultants responsible for the assessment have frequent calls with us to aid in implementing the required changes. They go on and on in our about how this is so great and how it's going to streamline everything. Pointed questions about existing regulations and laws that stand counter to the streamlining that is being evangelized by the consultants are are routinely brushed off with the refrain of, "well, the state of $State moves at the speed of the state of $State." They are also big on double-checking the law and regulations and like to tell stories about other centers and agencies that have been misled about what they should be doing to their detriment. While they are Not Wrong about this and many other things, the practical reality of the situation is that just as the law is whatever the judge says it is, the regulations and requirements are exactly what the auditors and Licensure say they are, and as we are highly unlikely to resort to litigation in order to resolve our differences, snitches getting stitches and all that, we will ultimately experience minimal gains from this.
As the Forms Guy, I am tasked with filling out a spreadsheet with every single form question in our EHR and identifying each of our forms in which it appears with the goal of deduplicating All of the Things. This turns out to be just shy of 4,000 unique questions, some of which are duplicated dozens of times, usually in free text fields like "notes" or "session details" that cannot be deduplicated. Worse still, many of the forms in question are State built forms and thus cannot practically be altered by those of us that are merely using them to report back to the state and so those data elements cannot be deduplicated either. I already ruthlessly cut redundancy and duplicity where I could; the low hanging fruit has been plucked and despite their insistence to the contrary, the reduction in duplicate effort and redundancy will be minimal at best. Of course, we do discover that absent consistent supervision and training on our existing workflows, staff and supervisors have developed their own procedures and documentation which needs to be brought into line, so the exercise as a whole does produce some positive results, it's just that ideally we'd be doing this ourselves anyway.
But wait! There's more! Medicaid requirements for clients have continued to evolve. Client intakes are no longer required to be service specific but are now expected to be a more comprehensive assessment of client needs. There is a hope among C-levels and supervisory staff that through the magic of Same Day Access (SDA) and the ability of clients to fill out their own forms in the client portal, clients will somehow provide the bulk of the necessary information themselves by filling out these forms! Given that many clients rely on our staff to help them navigate bureaucracy in the first place, and further that most of our staff do not understand the data they're supposed to be gathering from the clients I am beyond unimpressed with the shortsightedness of our collective management. Worse still, I am tasked with developing the client forms that will be created by a committee consisting of all program supervisors. When all is said and done, I have been given almost 100 questions that amount to a wish list of wants from each program. The majority of them are absurd, most especially the substance exposed infant questions that asks technical questions about the development of the baby. The darker, cynical cockles of my heart are thoroughly tickled by the whole affair and amongst those that I think can understand, I point to this episode as a prime example of Why We Can't Have Nice Things. I break down the questions into six separate client forms that clients will allegedly be filling out themselves while waiting to be seen. As. If.
This is not to say that the idea of same day access and getting clients into treatment as quickly as possible is flawed--far from it, in fact! And there are other good ideas in there as well! They have recommendations for dealing with chronic no-show clients, an issue endemic in our field and exacerbated by Medicaid regulations that disallow fees for clients that fail to show up. Neither do I disagree with the notion that engaging clients quickly and frequently leads to better outcomes than our current system of engaging them on at least a monthly basis. It is clear that more engagement is beneficial to clients on the whole! In the balance, however, this new model of providing services is not without its own issues and problems. Lower functioning clients, for example, tend to need dedicated case management just to be able to navigate their lives. And most tellingly, this new model requires complete commitment to its principle in order to have any reasonable chance of working well. And our state, as is its wont, is trying to graft it onto the existing structure and bureaucracies.
In other words, "Good luck, have fun!"
Apart from this fresh new hell, we are actively drowning in a sea of unintelligible data, administrative burden and technical debt. State level dashboards have become a Thing in and of themselves and are driving new and burdensome questions that are too technical for anyone outside of the MIS/IT department to understand with some exceptions for the COO and the CPO (Chief Program Officer). The three of us in said MIS/IT department are overwhelmed by our combination of help desk, clinical, MIS, and IT specific duties; it is hard to pay attention to server patching and security when also doing end-user support, EHR administration, and data analysis as required and none of us have the bandwidth to completely grok the entirety of the responsibilities of the others in our department. Developmental disability continues to be a rolling train wreck of continuous updates to data and documentation requirements and non-functioning interoperability between their website and the various EHRs. Our substance use program is growing with zero concerns about compliance or oversight for all intents and purposes. Medically assisted treatment has become Office Based Opioid Treatment (OBOT) and is flush with continued grant funding and consistent with this growth is widespread confusion amongst substance-use focused staff about how we report the services we're offering, particularly the difference between outpatient therapy, which is individual, and intensive outpatient therapy, which is group-based.
Time passes and with much effort and funding, Same Day Access manages to get off the ground. While we have managed to standardize our intake procedure, surprise, the clients are not in fact doing their own intakes when all is said and done. By virtue of serving disparate masters our new intake process is much more complicated and burdensome than the system that preceded However, we have several staff and a dedicated supervisor handling same day access at one clinic location and on a good day, each staff member can process several intakes each, netting perhaps a dozen intakes a day.
VI.
"Apres moi, le deluge." -Louis XV
It is 2021 and my boss and I are meeting with the supervisory staff of all programs and applicable C-levels to go over the data reporting requirements to which we are beholden. My boss, myself, and the special projects manager are the only ones in the agency left understanding how Same Day Access and its data gathering is supposed to work. It's on all the hot state dashboards and we are getting dinged for it regularly. Worse still, the data collection requirements have mushroomed, and we have gone from relatively straightforward things such as the date of first offered appointment after the same day access appointment to a twisty maze of collecting height, weight, and BMI, performing suicidality assessments on clients with diagnosis of depression and veterans, referring clients out for metabolic syndrome screening if they take psychotropic meds (and most of them either do or will) and reporting the results back to the state, performing primary care screenings, and the list goes on. We desperately want to convey this knowledge to the attendees, especially the complicated coordination that these workflows require in order for the data in question to even be reported at all, but most are busy texting on their phones, reading their emails, doing other work, and otherwise ignoring us. This is bad because not only are we drowning in a sea of unintelligible data and administrative burden, but there has been an exodus in upper management and the present staff are all that's left to pick up the pieces of responsibility that, at least on paper, was theirs all along.
The bill for serious amounts technical debt is now due and sending said debt to /dev/null is Bad Idea Jeans, which is of course exactly what we're doing. Every summer since the inception of the reporting of these outcomes I have multiple meetings where our system and documentation is blamed for our poor performance on the state dashboards. Every summer I explain that the outcomes in question are multi-step and require co-ordination between the staff filling out the forms and the staff doing the diagnosing in order for said outcomes to even be reported to the state. Lather, rinse, repeat.
If you're picturing an old-school flip clock changing its time display from 5:59 to 6:00 and I Got You Babe by Sonny and Cher playing on a radio, then you're picking up what I'm putting down.
AT this point, the level of client care we are giving varies based on which particular department is handling the client's needs. We have a spiffy new drug court program that is leveraging our OBOT program and clients in the counties where we have staff in place can enter pretty quickly. In other counties, not so much, but we'll get there. DD clients have their traditional barriers to access and crushing paperwork requirements, which is to say they generally wait years for any sort of significant aid. Traditional mental health client service is, in places, practically non-existent thanks to a nasty combination of COVID policies, which include dragooning case managers into managing telehealth appointments for the doctors and clients one day each week, the Great Resignation, and neglect on our part. Absent strong understanding and supervision, Same Day Access has dwindled and only several folks are able to be seen in an average day. A therapist I know had previously been a case manager a year ago and several of her clients still call her in an attempt to get services, stating that their case managers don't call them back and neither do their supervisors. Said therapist patiently explains that she can no longer even access their charts because HIPAA. She is working with a different population now and simply directs her former clients to file a human rights complaint with the State. This is not the only area where she is de facto performing the job duties for other staff, nor is she the only one I hear this from; my overall impression is that outside of the drug court services, traditional DD services, and access to psychiatrists, we don't seem to be doing much of anything for our clients these days.
It is 2022 and my boss has resigned. My interest in replacing him was tepid at its best and so the friend of $New_COO is brought in to manage IT. Thankfully, I really like $New_Boss as well, because I learn the hard way that I am too burned out to even get serious about finding another IT admin job. Even more thankfully, we've finally expanded the IT department to include a dedicated help desk position and another IT specialist and both are excellent--we might actually be able to leverage the more modern parts of our architecture to streamline some old processes! The CEO is retiring (for good!), however, at the end of the year and worse still, we are having serious problems recruiting and retaining staff for all of the reasons you'd expect, including the increased strain of the ever-evolving COVID lockdowns. We are still actively drowning in a sea of unintelligible data and administrative burden and our technical debt is still compounding at an alarming rate. Outside of the growth of OBOT and the drug courts, our client care is still at a low point. In true Orwellian fashion, potential clients are now showing up early in the morning, well before we open, in an attempt to be assessed through Same Day Access and actually get themselves into services. Worse still, the state has launched a new initiative to Unify All The Things and expects us to do their work for them participate in its implementation as the head of the project is not familiar with our existing bureaucracy. This, of course, bogs down quickly due to those pesky laws and regulations that command us to report things via specific processes and in specific formats that cannot be magically done away with. Time passes.
It is 2024 and I am attending yet another meeting pertaining to yet another attempt at Unifying All The Things. The first attempt, predictably, was retired quietly, but this time the state has hired The Pros From Dover and is implementing a data warehouse that is expected to be its source of truth moving forward. The ~120 data elements that we are currently reporting on a monthly basis, as well as a significant number other points of additional points of data from the TEDS dataset, are initially expected to be sent directly to the state on a real-time basis thanks to the magic of HL7. The timeline for implementation is about 18 months.
This time, they mean business.
We are still actively drowning in a sea of unintelligible data and administrative burden and our technical debt continues to compound despite the glaringly-obvious need in the approaching data warehouse implementation mentioned above. Worse still, the eye of Sauron is now upon us; the metrics on one of our dashboards is bad enough that we are on a PIP and will be expected to raise our performance in that metric in particular as well our metrics in general. But wait! There's more! The state is once again consulting with their foremost auditor, who had re-retired, to help them better understand their own data requirements. In addition to the increased burdens of making the sausage tidying our data on a daily instead of a monthly basis, it is reasonable for us to expect to be nit-picked on our inaccuracies and our failures as well!
Drug court and Office Based Addiction Treatment (Office Based Opioid Treatment, being so 2000-late, apparently) continues to chug along. DD clients have their traditional barriers to access and crushing paperwork requirements. Traditional mental health client service is, in places, almost nonexistent, but better than it was. In true Orwellian fashion, potential clients are still showing up early in the morning, well before we open, in an attempt to be assessed through Same Day Access and actually get themselves into services. On the bright side, COVID is officially over and at least our offices are open again, giving clients greater access to staff and better still, $New_New_CEO, in addition to wanting to run our organization more like a business (things are changing!), has implemented a "next business day" policy for returning phone calls and emails to further promote greater access to staff.
Why $New_New_CEO? Well that's a fun story in itself, but the essence is that $New_CEO turned out to be a disaster and a major disruptive force in her short-lived tenure, a powerful and terrible example of the Peter Principle. The bad news is that many senior figures have left for greener pastures during her tenure and though $New_new_CEO is much better (see above) the damage had been done and another large portion of our institutional knowledge is gone. Even scarier, amongst the new batch of senior figures in terms of institutional knowledge is... me. Like the previous senior figures, I am also still performing several jobs (the most concerning of which is the Maker of the Sausage Knower of the Data Specifications) and I, too, am burned out, tired of not being able to actually escape work, and frustrated with the constant stream of new and existing employees that are ignorant about the realities of our work (often deliberately so). And when $New_Management frequently bombards me with questions such as, "where is the workflow," and, "was this communicated," I want to scream at them that as a meager specialist, I have never been management, I have frequently pointed to where our existing documentation lies and have frequently communicated change in the past, and I have never had any actual authority to decide or enact any of this myself at all. And then follow that up with throwing a bunch of things and ragequitting.
$New_Boss recently said to me, "you know, when I first got here I thought there was no way it could be this bad and that you were just being a cynical asshole. Now I see that you were really just telling me the truth."
VII.
Whom the Gods would destroy, they first make mad. -Reverend William Anderson Scott
The sixties, for all intents and purposes, were a long time ago in a galaxy far, far away. The issue of mental health services is and always has been a quintessential wicked problem that we can really only try to improve at each iteration. As effective as the first and second wave drugs were in helping to treat mental illness, they have not lived up to the hopes that we had for them. Nor has deinstitutionalization led to universally better outcomes for clients and in fact, although I find the legal principle of O'Connor to be wonderful in theory, I believe that in practice and in the balance, it has been a cruelty to the more mentally ill among us. However, that's not to say that our outcomes are universally terrible. For all of their limitations, side effects, and potentially inflated prices, drugs are absolutely, positively the best bang for the buck treatment of mental illness at the community and society level. They provide relief from pervasive states of consciousness and a stability that clients simply cannot achieve without them. Unfortunately, I believe any greater outcome for any given individual would require that magical "willingness to change" that is, all too often, limited to nonexistent. Throw in a metric fuckton of data requirements that expect dust-speck fine levels of specificity and the whole rest of the medical bureaucracy with its various and sundry deep-reaching regulations and requirements, add in a staff that by and large doesn't have the technical chops to readily comprehend the difference between an assessment instrument and a diagnosis, and you've got a recipe for atrocious records and data that add up to little better than unreliable noise. Which means that practically speaking, a lot of this work is, to paraphrase the old Soviet joke, "we pretend to help and they pretend to be helped," with the real punchline being that on the national level, all of our data gathering is the garbage in, and the policies that result from that are the garbage out.
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Notes -
This was great - reminded me of Siderea's great blog series on the spiral of admin that afflicts modern healthcare: https://siderea.dreamwidth.org/1179450.html
Interesting piece, thanks for sharing! Reading a lot of that was intensely familiar, though I'd quibble with some of the premises of the series. But I was heartily amused by the talk of Axis II disorders in the DSM III and in fact had originally written a throwaway line about how over-represented personality disorders were on both sides of the mental health industry, but decided it would probably be too distracting. The psychotherapy CPT code graph was likewise spot-on and the talk about medical billing code complexity was as well. As the piece said, we in the MH field actually have it relatively easy, though anyone who's ever messed with interactive complexity knows full well that as with everything in this business, "easy" is relative!
I tend to think some of healthcare spend could be simplified as we regulate supply, subsidize demand, and then go shockedpikachuface.jpg when costs increase faster than inflation.
But the loop she identifies of admin is definitely not nothing and contributes to the regulation of supply.
I'm not sure there's an easy fix, I end up wondering if you just hope pharmacy innovation eventually gets you out of some of the trend (hep C drugs, HIV drugs, RSV vaccines, etc)
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Read every word. Interesting on many levels, not least that your perspective is from IT but really hits on all sorts of larger policy effects. Thanks for posting and taking the time to post.
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I’ve been on the IT side of healthcare, helpdesk with a few admin duties, and I do not envy you one bit.
Here are some of Ronald Reagan’s predictions from the 60’s about government-run healthcare:
These concerns seem almost quaint next to the never-ending grind of being at the intersection of public regulation, private underwriting, and technical debt.
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That's an intense history. I have a lot of sympathy for all the roles you've had to fill simply as part of IT administration. It was hard to follow certain elements of what your daily tasks were, but from what I could gather, it seems crazy how much access to protected health information you seem to have had. I would expect that HIPPA information would have been plugged into opaque databases a long time ago -- guess I have a lot to learn about healthcare bureaucracy!
The reluctance of clinical personnel to work with the systems was also somewhat surprising, particularly how many decided to quit rather than adapt. Do you think this was because they were nearing retirement, the systems were non-standard for the industry and so they decided to leave for greener pastures, or because working at a community mental health clinic was a tough position and the change in systems was the straw that broke the camel's back in pushing them to get a better job?
And this is why I don't agree with the legal reasoning in O'Connor. When we're talking about mental illnesses that make people unable to discern reality or care for themselves, we're talking about a population that, to put it bluntly, needs to be made to take their medication. Chronic moderate harm, not simply imminent bodily harm, to the individual and to society is far more damaging than we give it credit for. Every time I see the homeless beggar on the corner who can't control his movements, I feel that we've done a great deal of wrong to him and to all of us by letting him live on the street like an ancient leper and not putting him in an institution that can guarantee him a warm bed and a set of pills.
That being said, there are lots of reasons why people don't take their medication, the most sympathetic being that many antipsychotics come with all sorts of uncomfortable side effects, as you might expect for a class of drugs that mucks around with the dopaminergic system. Tardive dyskinesia seems horrible. But we can solve this problem with better drugs, and in the meantime the tough situation is that it's better for the patient and for everyone else if we keep them in touch with reality.
Remember that the people who are going to be forcing others to take their medication are human. They are quite capable of ignoring evidence, having preconceptions, etc. and that doesn't even consider the possibility of malice, either on the part of doctors, relatives, or the government.
This is a seen/unseen problem. Any problems that happen by forcing people to take medication will be out of sight, unlike the homeless beggar, and you won't easily be able to look at them and say "we gotta do something about this".
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Putting side effects and related problems aside (and they are severe, antipsychotics increase all cause mortality for example), many patients don't think they have a problem.
https://en.wikipedia.org/wiki/Anosognosia
It's a core symptom for many with psychotic illnesses and but many mood disorders or personality disorders involve people thinking nothing is wrong or blaming unrelated things.
Many of those with awareness of illness want to be free anyway, even if it means being miserable. Sometimes it is so they can do drugs. Sometimes it's because inpatient facilities suck.
Valuing autonomy is good but it leads to some grossness at times.
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Yeah, I apologize for the lack of clarity, my fingers are in so many different pies that it'd be hard to list them all. Off the top of my head, though, I'm still doing lots of data analyst and EHR admin as well as major pieces of the different data that we ship to our State for various departments and initiatives, Exchange admin, 365 admin, network admin, general server admin, help desk (we're all vulnerable to walk-ins, after all), some firewall/security stuff... in fact, I actually built an antispam server from open source wow, 21 years ago, and ran it until we modernized our network in 2011. That particular guy was one of my prouder accomplishments until I got into the guts of administering our current EHR platform. Anyway, the truth of the matter is that ever since that point and really earlier that on any given day I was putting out whatever fire was the biggest, if there was one, and if there wasn't then I was waiting for the inevitable.
On the whole HIPAA thing, yeah definitely not so much plugged into opaque databases. For all that the minimum necessary rule tries to restrict information, in the mental health world we do all kinds of wacky stuff that makes trying to even tamp down staff access difficult. When it comes to higher up stuff, most of the work we do is still wide open, though there are restricted clients that require an extra level of access, even to those that can generally access all clients with impunity. Fun fact: I actually had to go in and fix a family member's record not too long ago. They had been restricted because I worked there but still, someone made a mistake and there it was. I already knew said family member had gotten themselves TDO'ed so it just tickled my dark heart but if we had our act together and I was actually just doing IT proper stuff I'd never have to do that. And because I'm on the subject, I just can't even with all of the HIPAA breaches I've seen. Lots of them are genuine, "didn't get the memo/comprehend the training," type stuff like emailing documents with PHI in the wild, which our antispam gateway doesn't always catch, but there have been a few doozies, too. One of the saddest involved a staff who had somehow discovered that her boyfriend was also dating a client of ours, and said staff looked at the client's record and then proceeded to dig herself into a deeper hole trying to cover it up. Just a sad story and the only one I've seen prosecuted. Surprisingly, we've actually been forced to rehire staff that breached HIPAA and got terminated for it!
Anyway, I completely agree with you about needing a better standard than O'Connor and for me that's a real example of how my individualist ideals can lead to serious suffering in the real world. I can think of a few different "frequent flier" type clients that really would be better off institutionalized and that doesn't even touch clients that are homeless and suffering. And sadly, refusing medication for some of our most mentally ill clients goes hand in hand with being frequent fliers. I'm hopeful that we can find newer and better drugs for the folks that suffer from the terrible side effects (some folks do tend to think they're just fine without the meds) but then again, if you've ever read Scott's banger on esketamine, FDA approval is another thing on the long list of reasons that We Can't Have Nice Things.
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I'm going to admit that I mostly skimmed looking for clinical pearls, but you may find this article interesting.
https://www.politico.com/agenda/story/2017/03/vista-computer-history-va-conspiracy-000367/
Anything about your end of things that you think a doctor should know?
Yeah I don't mind the skimming at all, even though I had fun doing the repetition bit when I was writing the piece, it bloated it significantly. But this is the Motte, after all, and the one commenter who replied to me wanted the detail so I ended up going with it.
Can't think of anything that I could really tell you that you wouldn't have already encountered. I don't need to tell you how awful the healthcare bureaucracy is, right? Though maybe I will add that our most common doc issue is that they can't e-prescribe to the client because someone went and added a full address to the "address 2" field of the client profile, exceeding 40 characters and also obviously breaking address verification. That one ended up being thanks to an instruction from the clinical head who evidently was never taught Federal address standards...
If you're interested, our clinical side has largely been neglected in EHR land for the last 8 years as two different medical heads did not or did not want to get involved in that area. The next medical head pulled a Brave Sir Robin after trying her best to do that and still be a Psychiatrist for a year, and I can't blame her. I've been in a few meetings with the new head of medical, who is an old-timer, and have discovered that the institutional knowledge problem that I harp on is a big issue there as well, mostly because we could probably streamline some stuff out of the workflow for the docs (Meaningful Use has been over for a while, after all) but also because the nurses abandoned their actual note along the way and started using an outpatient note instead, leading to the loss of data and my employer getting its wrist slapped by the State. Definitely a LOL moment for me!
And thanks for the read, it had me sympathetically SMDH many times!
I thought that the repetition--even the word-for-word repetition--was very effective at conveying the spiral revolution of deja-vu same-but-now-even-worse. Thanks for writing it up!
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I thank god every day that I mostly use Epic (like at this point most damn doctors in the U.S.).
It sucks but it sucks way less than all the other options.
I don't know if you've run into any of this yet but AI assist tools are getting quite good. Should people be using them? Likely no, but they are hugely helpful.
I've only used Epic as a patient but from that perspective it's always seemed fine to me. My understanding is that on the other side of things, it's layers upon layers of complicated but then, so is the practice of medicine itself, so yeah.
AI is looking like we could probably feed it the bulk of our documentation and let it spit out nice notes for the majority of staff, but of course HIPAA. I don't use it much myself, personally, but then again I'm constantly context switching between our EHR side and our IT side and my personal goal is to pass on as much institutional knowledge as I can. I can remember when my old boss was jealous of me because I got to build fun things and learn while he had to ride herd on the clinical side. Now I'm doing what he did while the young IT Specialist is building fun things and learning new stuff. He did learn the hard way that anything he touches, he owns that way though!
Man you must have been around in the "shit I can't double click, I might as well just retire" days.
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