MaineHealth is an integrated healthcare system of leading, high-quality providers and other healthcare organizations working together across Central and Southern Maine. The Behavioral Health Integration program, a program of MaineHealth and Maine Behavioral Healthcare (a member of MaineHealth), consists of approximately thirty clinicians working in close to forty different practices within seven hospital system members of MaineHealth.  MaineHealth’s integration efforts started with grant funded pilot work in twenty practices around the state. There was great flexibility in trying a variety of models during this pilot work, which allowed the leadership of the integration program at MaineHealth to explore various levels of integration and decide what would work best for their needs.  It was deemed that the most effective and efficient method for integration was for providers to be able to work directly in the electronic medical record (EMR) and for those notes to be simultaneously used as a shared form of communication between providers.  MaineHealth has since adopted a system that promotes shared medical decision making by allowing providers to easily store and transmit patient information. 

Integrative Electronic Medical Records

At MaineHealth all primary care providers operate directly in the EMR with record keeping occurring in relatively real time.  The behavioral health specialist also works directly in the EMR and has the ability to view the patient’s entire medical record.  The EMR systems at MaineHealth feature a flag alert communication tool in which behavioral health and primary care providers can send messages to each other that are not part of the patient progress notes, but instead serve as internal instant message logs.  Primary care physicians receive complete feedback from the behavioral health provider both in person as well as by simply accessing the EMR when behavioral health providers route their notes directly to the primary care provider. 

The EMRs at MaineHealth incorporate a series of tools and patient engagement features used by both behavioral health providers and primary care physicians. The system incorporates PHQ9 screening for depression into the EMR as a standard behavioral health assessment.  MaineHealth also incorporates PHQ9 into their registries for some chronic health conditions.  The registry includes how many patients have been screened using PHQ9 and information regarding PHQ9 follow ups.  Although MaineHealth does not possess registries of specific psychiatric conditions, a behavioral health clinician looking for patient information regarding a psychiatric or behavioral health condition is able to do so through the integrated physician’s notes and any documents that come from other agencies around their mental health care.  All supplemental documents are scanned and electronically entered into the patient record.  Documentation of present behavioral health conditions is stored in the EMR during the patient visit. 

The EMR systems at MaineHealth also support the everyday needs of the office.  For example, the EMR includes a referral system that supports scheduling patients.  To promote integrated care MaineHealth encourages warm handoffs in which the provider directly introduces the patient to the behavioral health provider.  These warm handoffs can increase a patient’s trust level in the behavioral health provider and help to ensure the patient will follow up on their behavioral health needs.  While the warm handoffs occur in person, the EMR is used to log the order for a referral for behavioral health service so that front office staff can create and schedule the appointment electronically with the patient at check out. 

Addressing Confidentiality

MaineHealth recognizes the need to maintain confidentiality of records while employing health information technology for purposes of behavioral health integration.  A key priority is to always acknowledge that behavioral health records are sensitive and, as such, MaineHealth has enacted specific procedures for managing behavioral health records.  For example, the behavioral health portion of a patient medical record has limited access.  Since behavioral health information is protected by extra levels of sensitivity, there is specific access designated for doctors, nurses, and care managers to be able to access documentation coming from the behavioral health clinician.  MaineHealth recognizes the need to balance the ability to coordinate care with the need for privacy by ensuring that behavioral health information gets to the right people without allowing the information to flow unnecessarily to others.  Any information that does go outside of a particular hospital system within MaineHealth would need a release of information signed by the patient. 

When a patient is referred to a behavioral health clinician at MaineHealth, the patient is informed that information will be shared across their providers both electronically and in person.  If a patient is not comfortable with that sharing of information, the patient can be referred elsewhere.  The vast majority of patients, however, appreciate the sharing of information between their mental health providers and primary care clinicians.   Appreciation of these integrative efforts is part of why patients come to MaineHealth. 

Promoting Interoperability

At present there are 4 different electronic medical record (EMR) systems used by integrated behavioral health clinicians working in the MaineHealth hospital-owned primary care practices, although there are plans to continue to reduce the number of vendors.  In the meantime, MaineHealth has enacted efforts to promote interoperability and standardization across systems. 

Much progress has been made thus far in standardizing the typical documentation of the behavioral health clinician. The largest challenge in implementing health information technology systems for behavioral health integration has been the need to have someone in the IT systems available to build templates for behavioral health documentation and to create processes for storing behavioral health information.  None of the EMR systems in use at MaineHealth came with behavioral health templates that met their needs, so MaineHealth opted to develop their own templates that would be standardized across all of their HIT systems.  MaineHealth continues to work toward building templates that span all of behavioral health that can be incorporated into all of the electronic systems.  To assist in everyday needs, IT staff are connected to the hospital systems and are available to support primary care providers and behavioral health clinicians in all MaineHealth locations.