First of all, thanks to all who participated in the survey and who provided helpful feedback about it. As of noon on Saturday, January 17, I have received 658 responses. This is a tremendous response. To provide some context, the Minnesota Mental Health Work Force Group sent out a survey, using much more resources (the work group had 36 members) and allowing more time for responses. They received 500 responses.
Brief Background of the Survey
I decided to do the survey after reading a series of postings on two MPA listserv’s which voiced intense concerns, confusion, and anxiety about the MDH DHR Mandate. It occurred to me, after reflecting about the discussion threads, that it would be helpful to have some objective information about what psychologists and other mental health professionals know about the Mandate, their attitudes about it, and how they plan to respond. The idea for the survey came together for me while on vacation over the holidays, and I actually had a small window of time for creating using the SurveyMonkey program. There were a few challenges involved, as I had never used SurveyMonkey before, had limited time, and had to create the survey while riding on a plane using a laptop, and the ride was fairly bumpy. I tried to articulate the concerns posted on the listservs, and also to add other options to give a range of possible responses for participants. Once I was done, I posted it from the airplane. The free SurveyMonkey program allows for a maximum of 100 responses, and I had no idea how many responses I would get. I thought that it would be fortunate if I received anywhere close to 100.
After 24 hours I had received 98 responses, so I knew that I was on the something but also that I would need to upgrade my version of SurveyMonkey. I also found that there were some unfortunate typos that I did not catch due to the small font that I was working with on the laptop on the bumpy plane ride. Also, I received some feedback about some additional questions that were recommended by several people who completed the initial survey. I corrected the unfortunate typos, and also added two more questions. I also revised some of the initial questions to make the language more clear. I believe this resulted in a better survey, but obviously it “corrupted the data” and it should be clear that this is a fairly casual survey that is not intended to be a truly scientific and definitive survey of all mental health providers in the state.
I posted the invitation to participate in the survey on every local listserv that I could locate, and also purchased a list from the Minnesota Board of Psychology ($5.00 !) The latter list provided emails from most, but not all, psychologists are licensed by the Board as of December, 2014. Obviously, this is not a current list and to complicate things a bit further several hundred of the emails were obsolete. I also posted the invitation on several LinkedIn groups, and was told that several people passed on the link to other professional groups. Overall, I believe that at least 3000 professionals of various disciplines received the invitation. Since the invitation was sent by email, mostly using listserv groups, it should be obvious that this is not a broad sample of all mental health providers, particularly those who do not participate in listservs or are otherwise savvy and knowledgeable about Internet resources.
You’re welcome to view the entire survey results. The following is a summary of what strikes me is the highlights. Questions 2 and 6 offered the option of a narrative response, and due to the high number of responses I am unable provide analysis of all of this data, but you are welcome to review the responses, most of which expressed concerns and frustrations about the Mandate.
Question 1 (professional affiliation)
567 of the respondents, or 87.1%, were psychologists. The good news is that this provides, I believe, a fairly robust sample of 3,783 Minnesota Licensed psychologists. Obviously, this survey did not obtain a very good sample of the rest of mental health disciplines.
Question 2 (How did you learn about the Mandate?)
About 12% of the respondents had not been aware of the Mandate prior to receiving my request to participate in the survey. About 32% became aware of it as a result of being informed by their professional organization, and since most of the respondents are psychologist this would be MPA. About 27% became aware of the mandate by talking to a friend or colleague.
Question 3 (How do you assess your own understanding of the Mandate?)
Only about 18% of the respondents categorize themselves as having a “complete” understanding of the Mandate. Almost half, about 47%, view themselves as having partial understanding but feeling unclear about some of the mandate. About 21% view themselves as not understanding most of it, and about 14% stated that they feel overwhelmed by it and that they do not understand it. There obviously is considerable concern, at least among psychologists, about feeling that they do not have adequate understanding about this major development.
Question 4 (What is your understanding of the penalty for not having an EHR as of 1-1-15?)
About 82% of the respondents accurately understand that there is not yet a penalty for not having an EHR 2015. About 12% feared that they would be in trouble for not having an EHR by 1-1-15, and the remainder, about 6%, fear that they will be in trouble if they do not have an EHR by 6-30-15.
Question 5 (What is your understanding of how the Mandate will be enforced?)
About 70% of the respondents believe that it is unclear at this time how the mandate will be enforced. About 25% have the understanding that there is no known enforcement process at this time. About 6% of the respondents have the inaccurate understanding that there are audit processes in place for enforcement.
Question 6 (What is your current plan for responding to the Mandate?)
I’m providing the actual results for this question as I think that this information may be particularly helpful for those who are wondering how to respond to the Mandate.
I have already purchased an EHR in response to learning about the Mandate. 7.39%
I have an EHR that was purchased prior to learning about the Mandate. 9.97%
My organization has, or will provide, an EHR. 24.74%
I plan to purchase an EHR in the next 6 months. 5.84%
I plan to purchase an EHR by the end of 2015. 9.28%
I am not planning to purchase an EHR at this time. 10.14%
I plan to retire specifically because of the EHR Mandate. 5.15% (30 responds)
I plan to retire, but not because of the EHR Mandate, and will not purchase an EHR. 3.95%
I do not have a plan at this time. 23.54% (137 responses)
For this question I also provided an option for people to make comments, and I received 109 narrative responses. Most express intense concern about the mandate. This is more than I can summarize, but you’re welcome to view the actual responses. (scroll down to Q6)
It is striking to note that 30 respondents state that they plan to retire specifically because of the mandate. Also, only about 7% have purchased an EHR in response to the mandate.
Question 7 (What is your opinion about patient confidentiality with an EHR?)
Another striking finding is that about 43% of the respondents are “extremely” concerned about confidentiality problems that may be associated with EHR communications. Only about 17% are confident that patient confidentiality will be protected. About 40% are either unclear about whether there will be problems with confidentiality or have some concern about this.
Question 8 (What is your expectation about the technical challenges of learning to use an EHR?)
50% of the respondents are confident to being able to use EHR, and the rest are either concerned about this or unclear about what will be required to learn to use any HR.
Question 9 (How much do you expect to pay for an EHR?)
About 40% of the respondents are unclear about how much an EHR will cost. The 23% report that there employer has, or will provide, an EHR that they will be able to use. For those who will have two provide their own EHR and have an estimate of the expense, most expect it to cost more than $500 a year. About 6% have, or expect to use, a free EHR.
Question 10 (What is your assessment of your professional organization’s response to the Mandate?)
About 23% of the respondents are not a member of a professional organization. About 35% view their professional organization, for most of them this would be MPA obviously, as having provided helpful information about the Mandate. Another striking finding from this survey is that, unfortunately, about 42% of the participants view their professional organization, once again primarily MPA, as having not kept them adequately informed about the Mandate. This obviously identifies some potential opportunities for MPA to improve in this area.
Question 11 (What is your opinion about potential benefits of having an EHR?)
About 31% expect having an EHR to enhance coordination of care. Unfortunately, the remainder view having an EHR as either not improving coordination of care (about 34%) or as potentially causing harm (about 35%). This obviously signifies a major disconnect between the policy makers who have mandated that we have EHR’s, and are advocating for the benefits of this, and mental health professionals in the trenches who have significant concerns about EHR’s.
Question 12 (If given a choice, would you opt out of using an EHR?)
Finally, another striking finding is that, if given the option of opting out of using an EHR, 70% of the respondents would do this.
It is clear that many, probably a majority, of psychologists have strong concerns about the Mandate and are opposed to it. Many view their professional organization, primarily MPA, as having “dropped the ball” in regard to monitoring their concerns and advocating for their members.
Many postings on MPA listservs and the narrative comments on my survey advocate for trying to get the Mandate rescinded. This is all very unfortunate, as the Mandate was established by law, not the MDH, and the chances of getting it rescinded are slim-to-none. On the other hand, there has been some discussion about getting it altered, primary to address confidentiality concerns. The chances of this are, I believe, slim- but this may be worth a try. For those who are interested in this, see the “Resources” section below for information about a potential petition for change.
EHR’s clearly are going to be significant part of health care reform, and there are many powerful forces that driving these reforms. In order to have any impact, it will be necessary for mental health professionals to get a lot more organized and to speak more as a group. Joining your state professional organization and being an active member is the most effective way to do this- but then this leaves us with questions about whether these organizations can function in competent and effective ways that meet the needs of their members. The survey appears to indicate that a significant number of psychologists view MPA as having not met their needs in regard to the Mandate. This leaves MPA, I suggest, with the responsibility of demonstrating to the members, and psychologists considering becoming members, that the organization understands the needs and concerns of Minnesota psychologists and can respond to them more effectively than it has done in the past.
Also, the survey finds that some mental health professionals have much more positive attitudes about the Mandate, have either purchased an EHR or in the process of this, and view having an EHR as helping with exchange of information and coordination of care for the people who matter the most, their patients.
Finally, the survey finds that many participants are in need of more information about the Mandate and EHRs. One option for this would be to sign up for my (see the “sign up for email” option on the right) and I will be posting regular updates about the issues involved and options for responding. It seems, at least to me, to be advisable for those who do not have an EHR to make sure that they are exchanging information and coordinating care with their patient’s psychiatrist, primary care provider and any other health care professionals who are important players in the patient’s health care. This is both good clinical practice and also may potentially help your case if you somehow come to someone’s attention for being out of compliance with the Mandate (I think that this is extremely unlikely, at least in 2015, but you will want to track how the Mandate is enforced over the next several years).
The Minnesota Department of Health website has several documents, but -as is often the case for MDH and other state agencies – they are written in somewhat dense and bureaucratic language. Many mental health professionals experience abrupt and profound cognitive fatigue when reading such documents, but it is important to get informed and worth at least looking at some of the documents. A good one to start with is Guidance for Understanding the Minnesota 2015 Interoperable EHR Mandate. This document has several links to other resources, but understanding many of the documents requires some understanding of basic concepts such as “inter-interoperability” and “HIE” (health information exchange) technologies. I will be researching all of this and posting regularly, at least monthly, on my blog as a work on my own understanding of the Mandate and my own plan for managing the requirements of the Mandate as a solo practitioner.
Stephen Huey, Ph.D., L.P. has a website with his open letter to fellow psychotherapists and a very through and thoughtful document in support of his concerns (25 pp!) Steve clearly has tapped into the concerns of many fellow psychotherapists. He is advocating for a petition, and if you would like to participate you should contact him at firstname.lastname@example.org. If you have not yet read his documents, I highly recommend that you take a look at them, as they are excellent sources of information, explained in non-bureaucratic English, and he also provides thoughtful commentary.
I have an article about coordination of care, written with a psychiatrist colleague, John Simon, MD, that has been accepted for publication by a local magazine, “Minnesota Physician,” in their next issue. Dr. Simon and I discuss coordination of care between between behavioral specialists, particularly psychiatrists and therapists, and also between behavioral specialists and primary medical providers. We discuss the benefits of coordination of care, current barriers to adequate coordination of care and options for overcoming these barriers. I will provide a posting on my blog when the magazine is published and the article is available to the professional community. You could also keep an eye out for free copies that are often available at medical buildings. You may also consider attending the publisher’s upcoming Minnesota Health Care Roundtable, “The New Face of Health Care: expanding medical professional relationships.” The conference objectives are:
We will examine many of the new partnerships that are emerging between medical doctors and other medical professionals. We will look at the ways leveraging these new relationships can improve access to care while reducing costs and improving outcomes. We will consider points of resistance to forming these kinds of health care teams and what should be avoided in creating them. We will discuss what the proper oversight for these relationships should entail and how to maximize the coordination of care that they require.
I recommend it for both for learning about expanding relationships with medical professionals and as an excellent opportunity for networking with medical colleagues.
I will post regular, probably about monthly, updates about the Mandate and coordination of care issues on my blog, and you are welcome to sign up my blog.