July 2009In This Issue

1 Cover StoryThe Revolution of Mind & Body Understanding: Prepare to Use Emerging Science to Guide Your Organization’s Future Vision

2 Industry ProfilesMental Health Center of DenverGrafton, Inc.

4 Managing in the 21st CenturyHow Competent is Your Management Team?: New Challenges in Behavioral Health & Social Services Require a New Skill Set

5 Tracking the Consumer RevolutionAdoption of Recovery-Oriented Care Systems Growing: A Look at the ‘State of the Nation’

6 Industry AnalysisKnowing the Professional Risk of the Recovery Model: Policy & Legal Precedents Can be at Odds

8 Survival of the SmartestGetting Ready for Electronic Health Records: Technology & Staff Support Infrastructure Tips to Get You Started

9 Science to ServiceAnnual Costs of Bipolar Disorder Top $12,000: Treatment of Comorbid Conditions Around 70% of Annual Costs

10 Innovation WatchExpand Cognitive Functioning Via New Technologies Key Considerations for Trying These ‘New Wave’ Technologies in Your Current Model

12 Market UpdateOPEN MINDS Electronic Health Records Update: The Wheels in Washington Move Slowly But Surely to Shape Health Information Policy

VOLUME 21 ISSUE 4

OPEN MINDSThe Behavioral Health & Social Service Industry Analyst

http://www.openminds.com/educ/omi2009el.htm

VOLUME 21 ISSUE 4

OPEN MINDSThe Behavioral Health & Social Service Industry Analyst

I had an opportunity to hear a lecture delivered by Thomas Insel, M.D., a psychiatrist and the direc-tor of the National Institute of Mental Health while attending the Chautauqua Institution’s week-long program, “State of Mind.” The lecture’s overarch-ing theme was one of the evolution of scientific understanding and of health care practice. Dr. Insel stressed the importance of the revolution of understanding about the relationship between the mind and the body (and our ability to draw links

between them) to the scientific and health care community. Throughout the presentation, he illuminated “new discoveries” that are shaping prac-tice—while being quick to point out that we are “only 10%” on the way to understanding complex brain functioning.

Dr. Insel gave the Chautauqua audience both the official and unofficial definition of neuroscience. Officially, it is the understanding of how the brain works. The unofficial definition is that brain science extends “from neurons to neighborhoods.” Dr. Insel told the audience how the basic assumptions in psychiatry have changed—due to neuroscience—since he was in medical school, and that he believes advances in neuroscience emerged with the evolution of brain scanning, which allowed scientists to “visualize changes” to the brain. Our new understandings of neuroscience have ended three great myths in the mental health field:

Myth # 1: Brain development is done at birth. We now know that brain development is not complete until approximately age 25. From that point forth, we lose brain cells at the rate of 50,000 or so per day, but the human body continues to generate new brain cells throughout our lifetime. Myth # 2: The brain is an organ with static functioning. We now know that the brain is “plastic” and capable of change. In fact, new research indicates that the cells and size of the hippocampus actually grow when adults engage in new learning. Myth # 3: Specifi c human functions happen in specifi c regions of the brain. We now know that brain functioning is not limited to a single location. For example, ‘vision’ happens in many coordinated locations of the brain—as does language. Old models of the brain (remember your junior high health class) where a specifi c spot in the brain controlled a certain function just are not accurate.

Dr. Insel believes that this new knowledge has already affected the treat-ment of behavioral and neurological disorders—that we are moving from the study of treatment of these diseases using psychological principles alone, to combining knowledge of psychology and behavior with neu-roscience. But, our current treatments are still quite primitive. We know that medication is necessary, but not sufficient alone. We are certainly headed towards linking neuroscience to prevention by harnessing the brain’s ability to continue to create new cells. Dr. Insel suggested three likely future effects of neuroscience on treatment:

First, treatments will develop based on our understanding of the differ-ence in behavioral/neurological diseases in terms of the death of cells ver-sus the faulty circuitry of cells. A whole group of conditions are related to the death of cells (Parkinson’s disease, ALS, Alzheimer’s) while others (schizophrenia, bipolar disorder) are a function of faulty communica-tion/circuitry between cells. This understanding will drive new treatment approaches.

Second, developments in neuroscience will eventually allow mental health professionals to move ‘upstream’ in preventing mental illness, much like the treatment of heart disease. New scanning technologies will allow us to detect changes in brain cells earlier—and to intervene to pre-vent (or delay) symptomatology. Although there is no predictive testing (via scanning, genomics, or biological testing) now for mental illnesses, addictions, or Alzheimer’s disease, such testing is in the research pipeline.

Third, the future of mental health treatment is to direct the development of new brain cells. New research shows us that most serious mental ill-nesses start (though they may not be diagnosed) before human brains are

fully developed. The key is to detect and prevent brain development from going far off course.

What does this mean for organizations either paying for or providing treatment services for behavioral disorders? I think there are two important manage-ment implications from Dr. Insel’s remarks. First, clinical directors need to embrace emerging sci-entific findings and adopt a program development framework with the assumption that neuroscience will enhance—rather than conflict with—current psychological and social approaches. Secondly, for the near future, brain scanning technology is going

to be central to ‘state of the art’ programming for the prevention, diagno-sis, and treatment of behavioral disorders. To continue to be ‘state of the art’, most programs in the field will need to develop collaborations with professionals with brain scanning expertise.

In his closing, Dr. Insel emphasized the importance of these issues in the current health care policy discussion. He referred to lack of parity in health care benefits for behavioral disorders as “discrimination” and expressed concern about how effective the soon-to-be-implemented par-ity legislation will be. His point was illustrated by the statistics (which we know too well) about people with mental illness residing in jails and homeless shelters; the fact that the leading cause of disability—50%—for Americans under 45 is mental illness and/or addiction; and that while we have 18,000 homicides in the U.S. each year, there are over 30,000 suicides, 90% of which are linked to mental illness. Creating a national dialogue on ending discrimination in treatment needs to happen now, and understanding the emerging implications of ongoing scientific research needs to be part of the discussion.

By Monica E. Oss, Chief Executive Officer, OPEN MINDSTelephone 717-334-1329; E-mail: monicaoss@openminds.com

The Revolution of Mind & Body Understanding:Prepare to Use Emerging Science to Guide the Vision of Your Organization’s Future

July 2009

Monica E. Oss

Clinical directors need to embrace emerging scientific

findings and adopt a program development framework with the

assumption that neuroscience will enhance—rather than conflict

with—current psychological and social approaches.

OPEN MINDS — July 2009

www.openminds.com

I n d u s t r y P r o f i l e

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Mental Health Center of DenverThe Mental Health Center of Denver (MHCD) was formed in 1989 as the desig-nated community mental health authority for the city and county of Denver. This greatly improved Denver’s mental health services and accessibility, structural and administra-tive efficiencies, and consumer variables. MHCD has continued to serve as a private non-profit organization for all Denver resi-dents in need of (and eligible for) mental health services and programs. MHCD is Colorado’s only community-based center

with specialized mental health services for deaf and hard of hearing individuals and also provides mental health services to individuals, family, friends and caregivers of those affected by HIV/AIDS. Over the years, a 70% recovery rate has been seen in those who were treated at the Mental Health Center of Denver. In 2008, MHCD served 11,500 people with ‘core clinical services’ and aided approximately 24,000 additional individuals on the road to recov-ery. With total revenue of $50,537,908 for 2007, MHCD provides a broad range of services to youth and adults coping with serious mental illness. MHCD has over 95 professional affiliations and contracts with both community and national organizations, and employs over 500 pro-fessionals. Main services include:

2Succeed in Education & EmploymentChild & Family ServicesAdult Recovery Services

2Succeed in Education & Employment 2Succeed in Education is a comprehensive program forwarding academic, career, and personal development in people with serious and persistent mental illness. Academic development services staff cooperate with area educational institutions to assist students with financial aid and disability services. They also tutor, lead support groups, and provide information about psychological disabilities and recovery. 2Succeed also offers well-ness and learning services like mind/body/spirit class and medita-tion, as well as wellness recovery and action plans. Over 70 clients in 2Succeed’s program are now attending college or working on their applications for school or financial aid.2Succeed in Employment offers a multitude of employment services, ultimately working with consumers and area businesses to develop productive employer-employee relations. MHCD along with Bayaud Industries and Denver’s Road to Work has partnered with five local hotels in order to provide employment opportunities for consumers. Projects With Industry (PWI) grant funds from the U.S. Department of Education and Rehabilitation Service Administration support the pro-gram, which provides supported employment services for individuals interested in the hospitality industry. Statistics indicate that 42 consum-ers have found work and 23 have worked 3 months or longer. 2Succeed in Employment has recently been asked to participate in a Social Security Administration Mental Health study in order to help people with mental illness on disability return to work and leave benefits.

Child & Family Services MHCD Child & Family Services sup-port the needs of growing children and families coping with serious emotional disturbances (SED). Individualized treatment in community-based settings include assessment and evaluation services; medication evaluation and management; crisis intervention; case management, care coordination, and referrals; intensive in-home family therapy; and a Therapeutic Day Treatment program. MHCD also has a Promoting Early Childhood Attachment, Resilience and Life Skills (PEARL) Program, an outcomes-based prevention and early intervention program providing on-site clinical and educational resources such as classroom support for teachers, individualized treat-ment plans for children and their families, consultation services for center or program administrators, and linkages to community resources. PEARL has seen significant improvement in children’s behavior, improved competencies of teachers and caregivers in dealing with and detecting stress in young children, and improved parental ability to nur-ture/support their children. MCHD collaborates with 16 Denver Public schools, providing mental health care to over 900 students and their families. Intensive In-Home Family Therapy serves children and youth with SED and disruptive or delinquent behavior that are at risk of hospitalization, juvenile detention, or out-of-home placement. Treatment may include full-day educational and therapeutic services; individualized education plans to meet educational and emotional needs; as well as psychiatric services, medication and case management, and family support services.Adult Recovery Services At MHCD, individuals 18 or older with significant mental illness qualify for Adult Outpatient Services acces-sible at seven different adult outpatient clinics serving Denver. With individual treatment plans and cross-disciplinary teams of behavioral health specialists and support staff, services are extensive and include crisis and emergency services; counseling; case management; medical care, housing resources, psychiatric evaluation, medication prescribing and monitoring; and psycho-education. MHCD Residential Programs are held in 18 licensed assisted living res-idences designed as alternatives to hospitalization. Two of these facili-ties are part of Substance Use Recovery Gaining Empowerment special-izing in Integrated Dual Diagnosis Treatment. Congregate Apartments are also offered, with MHCD overseeing five apartment buildings that provide consumers the opportunities for independent living. Intensive Case Management (ICM) for the homeless or those at-risk of homelessness was formed after the settlement of a class action law suit against the City of Denver and the State of Colorado on behalf of underserved mental health consumers. The settlement of the lawsuit resulted in the State contracting with MHCD to provide special services to adults recovering from mental illness that are also homeless or at risk of being hospitalized.MHCD’s Growth and Recovery Opportunities for Women program, funded in part by the Substance Abuse & Mental Health Services Administration, has helped all 41 women who were homeless find a permanent place to live; 67% of these women are abstaining from sub-stance use, and many now have jobs or are attending school. MCHD’s collaboration with Street to Home has provided treatment and housing

to 45 homeless adults with substance abuse and mental illness.MCHD also provides help to repeat jail offenders with untreated mental illnesses with its jail diversion program, Court to Community. This program has seen a 70% success rate in reduc-tion of re-arrests and an 80% decrease in days spent in jail. Over $100,000 in taxpayer’s money has been saved within an 18-month period. Recent findings show at program completion, the ratio of public service savings to treatment costs was 93 cents for each dollar spent in treatment costs per consumer.

Mental Health Center of Denver4141 E. Dickenson PlaceDenver, Colorado 80222Telephone: 303-504-6500Fax: 303-757-5245E-mail: ContactMHCD@MHCD.orgWeb site: www.mhcd.org

Key Officers & ExecutivesCarl Clark, M.D., Chief Executive Officer Forrest Cason, Chief Financial OfficerCheryl Clark, M.D., Medical Director Theresa Baiotto, Executive Assistant

OPEN MINDS — July 2009

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I n d u s t r y P r o f i l e

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Grafton, Inc.With more than 50 years of experience in behavioral sciences to draw upon, Grafton has a deep understanding of the specific disabilities, needs, and issues that confront at-risk children and their families. The organization was founded in 1958 by Ruth Birch, a parent unable to acquire public school services for her son due to his learning disability. Building upon that innovation and a philosophy of client-focused, highly individualized care, over the past five decades this non-profit organiza-tion has become a nationally recognized leader in behavioral health care.

Grafton provides a continuum of services to Virginia children, ado-lescents and adults with co-occurring intellectual, developmental and psychiatric disabilities. It has earned a reputation for utilizing evidence-based best practices to ‘deliver solutions that last’ for clients present-ing the most difficult challenges. Grafton currently has more than 700 employees and supports more than 400 clients per year in a trauma-sen-sitive, evidenced-based treatment milieu. For fiscal year 2008, revenues totaled $36,694,235. Grafton provides services in the following areas:

Residential ServicesTherapeutic Services Education Services

Residential Services Grafton’s Berryville campus functions as a Psychiatric Residential Treatment Facility (PRTF) supporting clients ages six to 21 with acute psychiatric diagnoses (i.e. schizophrenia, mood disorders, anxiety disorders, dissociative disorders, sexual and gender identity disorders, etc.) in addition to existing intellectual disabilities. Grafton’s other two facilities, located in Richmond and Winchester, Virginia, provide community-based group homes and special education supporting children and adults with autism or other pervasive intellectual disabilities. Clients at these two locations may also have a concurrent psychiatric condition.

Around 54.5% of Grafton’s annual revenue for the fiscal year 2008 went toward residential services. In dorms or group homes, clients are provided a degree of independence but also assistance and support from professionals. Grafton provides 24-hour residential support whenever needed—including psychiatric and nursing services—with an emphasis on focused care and treatment designed to increase functional autonomy and build community connections. Young student group facilities are composed of dorms and large rooms for socialization and recreational activities, as well as a gym and cafeteria. Students in these facilities are provided constant supervised support until they graduate as young adults and move on to “group homes.” Grafton’s psychiatric residential treat-ment facility was granted a three-year CARF accreditation, an exem-plary rating that only 3% of organizations nationwide receive.

Therapeutic Services Grafton’s therapeutic services include thera-pies for families and individuals, expressive, occupational, and speech language therapy, case management, and positive behavior support. Individualized, behavioral consultations are given for families, schools and other agencies. About 4% of Grafton’s annual revenue in 2008 went towards therapeutic/clinical services. Grafton uses Early Periodic

Screening Diagnosis and Treatment (EPSDT) for chil-dren. This comprehensive, preventive health program for individuals under 21 captures service previously not offered by Medicaid for children with developmental disabilities and brain injury. Short-term diagnostics and assessments are also provided. Evaluations and treatment focus on speech, occupational, vocational, and neurologi-cal therapy. Grafton also supports the Virginia Autism Resource Center (VARC), a statewide project that helps diagnose individuals with autism and provides the necessary resources to help those with the disorder. In 2008, 0.54% of Grafton’s revenue went towards VARC. Training, consultations, materials and information are provided for children, ado-lescents and adults with autism (and similar disorders), families, educa-tors, public or private agency personnel, case managers, social workers, psychologists, physicians, and students.

Education Services Grafton’s main lines of treatment under its educa-tion services include social skills development, stress and anger manage-ment, life skills instruction, recreational activities, and community inte-gration. The Adult Day Activities Program Team (ADAPT) is a center-based initiative providing a range of social, physical, educational, and recreational activities to adults with disabilities. ADAPT aims to enrich the lives of adults by providing social interaction, creative expression, and personal growth. Activities include art therapy, music therapy, and swimming. Educational field trips are also provided on occasion. The program has evolved over the years into the ADAPT Board of Directors and Grafton Adult Services and has partnered with the Advocacy Committee of the Arc of the Northern Shenandoah Valley in its commu-nity service efforts. 15.79% of Grafton’s revenue in 2008 went towards these adult services.

Children’s education services include certified and accredited Special Education programs that are provided in both classroom and residential settings. Last year, 22.35% of Grafton’s revenue went towards stu-dent education services. Psychiatric and developmental disabilities are addressed as well as cerebral palsy and sensory impairments. Grafton’s special education program follows Virginia’s Standards of Learning in English, reading, math, history, social science, and science, but also modifies the curricular programs based on assessment, transition—and each student’s abilities and interests—in order to acknowledge indi-vidual strengths and to motivate students. One-on-one curriculum in daily living, occupational preparation, guidance, and community living skills are also provided—based on each child’s needs—and accounted for 1.41% of Grafton’s annual revenue in 2008.

Grafton actively supports and educates those working in public and pri-vate agencies so that they can give individuals with disabilities in their community settings optimal care. Grafton also provides leadership/man-agement development and workshops with an emphasis on alternatives to restraint and seclusion. The main goal of these services is to provide individualized care and support to both children and adults while also

focusing on possible transition and dis-charge.

Grafton has been honored with sev-eral recognitions, including the Negley President’s Award for its “Minimization of Restraint” initiative for excellence in risk management practices in 2008.

Grafton, Inc.P.O. Box 2500Winchester, Virginia 22604Phone: 888-955-5205 Fax: 540-542-1722 E-mail: admissions@grafton.orgWeb site: www.grafton.org

Key Officers & ExecutivesJames G. Gaynor II, President & Chief Executive Officer Dana J. Papke, Executive Vice President & Chief Operating OfficerJames H. Stewart, Executive Vice President & Chief Administrative OfficerDavid P. Applewood, Chief Financial OfficerWilliam F. Davis, Chief Information Officer

OPEN MINDS — July 2009

www.openminds.com

It is a whole new world for today’s managers in behav-ioral health and social services. For many organiza-tions, economic pressures are making survival a seri-ous challenge. In this environment all managers must know how to manage to the bottom line; they must understand concepts such as ‘unit costs,’ ‘productivity,’ and ‘workflow analysis.’ But these are only few of the many new developments in our field impacting how managers do their jobs.

Today’s managers must ensure fidelity to the evidence-based practices being internally utilized at their organizations, and monitor all perfor-mance-based contract requirements. It is also the responsibility of manag-ers to ensure that their program or department meets all applicable com-pliance requirements. Managers must work with staff to ensure that new technologies—to mange information and to provide treatment via new modalities (i.e. e-health)—are properly implemented and utilized for both client and organizational maximum benefit. The increasing utilization of community-based programs means that managers will have to develop new skills in ‘remote supervision’—that is, supervising employees who spend most of their time in the community with clients. Furthermore, all managers must be change agents, helping to lead their organizations through times of great challenge and into great opportunities. The OPEN MINDS team has identified five key pillars of management competencies for behavioral health and social service managers now and in the future. Essentially the competencies are the enduring char-acteristics or ‘talents’ that determine individual performance. Using a competency-based approach will allow you to clearly identify the specific skills needed by each of the members of your management team. You can then design job descriptions and performance evaluations to reflect those competencies. Other than simply relying on your own observations, how can you assess these competencies? First, make sure that all assessments are done in the context of your strategic plan. Ultimately, what matters is whether your management team has the required competencies to imple-ment the organization’s strategic plan—the strategies and objectives, as measured by key performance indicators. One useful tool is the 360-degree evaluation. This is a multi-rater sur-vey where managers’ performance is measured through a variety of perspectives—self-evaluation, evaluation by the manager’s immediate

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M a n a g i n g i n t h e 2 1 s t C e n t u r y

How Competent is Your Management Team?:New Challenges in Behavioral Health & Social Services Require a New Skill Set

supervisor(s), management peer evaluations, and evaluations via direct reports. The 360 survey should be designed so that each management team member is rated (by all raters) for proficiency in each of the execu-tive competencies. It is often a good idea to develop a behavioral descrip-tion for each competency to ensure greater inter-rater reliability. For example, a behavioral description for the talent management executive competency could be: “Recognizes and develops leadership capacity in direct reports.” If necessary, more than one behavioral description can be developed for each competency. Competency assessment results should be aggregated both for the team as a whole and for each member of the management team. This will allow you to then identify developmental needs for both individual managers and for the overall management team. You must then develop action plans to address these needs. Elements of the action plans can include training geared to address gaps in competencies, mentoring, and/or the identifi-cation of specific assignments designed to build strengths in particular competencies. Keep in mind that the competency assessment process should not be con-fined to the senior management team. Middle managers—those mangers that supervise front line employees—make up one of the most important groups in your organization. These managers work directly with staff and are critical for the success of your organization. It is therefore important to assess their management competencies as well. You can modify the executive competencies as needed to fit the duties of the middle manag-ers. For example, a day treatment program supervisor may not deal with the board of directors, and thus would not be expected to be adept in that competency area, but he or she must have competency in budgeting and financial management. Either way, it is critical to conduct some type of evaluation and then implement the appropriate developmental plan.In future issues, I will address some of the specific management compe-tencies outlined in this column and will discuss common management challenges. In the meantime, I encourage you to send your thoughts, questions, experiences, challenges, and ideas, as your input is integral in establishing a continuous dialogue regarding developments and changes in the behavioral health and social service field.

By John F. Talbot, Ph.D., Executive Vice President, OPEN MINDS, Telephone: 717-334-1329; E-mail: jtalbot@openminds.com

Janet Buchanan

John Talbot

OPEN MINDS — July 2009

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tion, integrated treatment, and peer recovery support services. This rule change served as the groundwork for larger system change efforts in the state. Michigan is working to integrate a wide range of systems, including corrections, child welfare, state police, and education into their recovery-oriented activities. Next steps for Michigan include forming ROSC work-groups, continuing policy development, enhancing monitoring at various levels, and integrating technical advisory group recommendations.

Since 2006, Oregon has planned to gradually phase in a ROSC. The Addictions and Mental Health Division (AMH) at Oregon’s Department of Human Services has devised the Resilience and Recovery Policy Statement, which places more of an emphasis on the consumer and pro-vider experience, focus groups, data analyses of their programs and poli-cies, and evidence-based practices. It also promotes the use of Recovery Homes/Oxford Houses—group homes throughout various metropolitan areas that allow for self-run/self-supportive drug-free recovery environ-ments. AMH essentially aims to create a holistic, self-directed recovery process that allows each client to take control of every aspect of his or her life. AMH’s outcomes involve success in school, work, and personal relationships; improved health; community involvement; and an overall increased quality of life for both the individual and family involved. Oregon is further examining payment strategies and regulatory issues (e.g. administration rules and processes). Main concerns for the develop-ment of Oregon’s ROSC is peer-delivered services as well as the inclu-sion of case management into the Medicaid benefi t package.

The city of Philadelphia’s Department of Behavioral Health and Mental Retardation Services (DBH/MRS) is also undergoing a transformation in their system. DBH/MRS has begun a process of systems change with early identifi cation and increased use of assessment tools as well as ser-vice retention. The ability of clients to take control of their own recover-ies is now emphasized, as well as a natural learning environment and welcoming attitude towards re-admitted clients. DBH/MRS also plans on improving the quality of service relationships; increasing total services (while decreasing acute care episodes); and on providing post-treatment checkups and support. Philadelphia has collaborated with various organi-zations with these goals in mind and has formed community coalitions, awarded grants to community-based organizations and providers, and has supported faith-based initiatives.

The Wellbriety Movement in Native American communities is based on the Four Laws of Change for community development as well as on the traditional 12-step program from Alcoholics Anonymous; this integra-tion represents culturally specific healing in the development of a ROSC. Recovery-oriented elements of the Wellbriety Movement include peer recovery support networks, ongoing monitoring and outreach, education and training, and an emphasis on cultural responsiveness, family involve-ment, and person-centered treatment elements.

This article has taken a look at the state-of-the-nation, and although ROSC implementation is presently limited, we can all encourage their growth and development through exploration and discussion.

By Dan M. Aune, M.S.W., Senior Consultant, OPEN MINDSTelephone: 717-334-1329; E-mail: daune@openminds.com

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Tr a c k i n g t h e C o n s u m e r R e v o l u t i o n

Adoption of Recovery-Oriented Care Systems Growing:A Look at the ‘State of the Nation’

Dan M. Aune

The ‘state of the nation’ in recovery-oriented systems of care (ROSC) is a moving target with a mass of anecdotal information but little hard data. An ROSC is a system designed to meet the needs of the consumer with recognition that each person must either lead or be the central participant in his or her own recovery. The integration of an ROSC will involve many changes to current systems of care, requiring different state and fed-eral agencies to work together and rethink goals and priorities. A common question I hear from provider organizations is, “How do we know this can work and what are others doing across the country?”

State of the NationStates are at different stages in conceptualizing and implementing recov-ery-oriented systems change, according to “Partners for Recovery,” a 2008 report issued by Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse (CSAT). While the report primarily focuses on substance abuse, it can be utilized as a good indicator of the pace of development in both substance abuse and mental health fields. According to the report, fi ve states have begun planning, actively adapting, and re-engineering their systems of care to become more recovery-oriented; eighteen states are implementing system elements and are beginning to plan implementation of ROSCs; twenty-two states are implementing one or more system elements; and six states are considering implementation of ROSCs.

The participants in the report demonstrate the diversity of ROSC devel-opment and interest. Those in attendance included 17 Single State Authorities (SSA) and 34 SSA designees; 50 treatment providers or treatment provider association representatives; 48 representatives of recovery organizations or of the recovering community; eight faith-based providers; two recovery/faith-based providers; one treatment/faith-based provider; 20 research representatives; and 30 other types of stakeholders. Such diversity in representation and geography demonstrates the per-vasively high level of interest in the development of ROSCs. However, a few states and tribal nations have endorsed the ROSC model and are setting the pace: Arizona, Connecticut, Michigan, Oregon, the city of Philadelphia, and the Native American Wellbriety Movement.

In 2001, the Arizona Department of Health Services, Division of Behavioral Health, shifted its system to include the reliance on licensed provider agencies and the development of non-traditional support provid-ers. The transformation goals included diversifi cation and expansion of the workforce through non-traditional providers, the maximization of Medicaid reimbursement for a growing entitled population, employing the Health Care Common Procedures Coding System’s “H” codes for sub-stance abuse, mental health, and behavioral health services for reimburse-ment by the Centers for Medicare and Medicaid Services, and developing an 80-hour class in skill and competencies of peer support specialists.

Connecticut’s ROSC integration strategy included a multi-year imple-mentation process including consensus building; technology transfers to utilize ‘best practices’; incorporating existing initiatives; re-orientation of systems to support recovery; the transition of providers to recovery-ori-ented performance outcomes; the development of “Practice Guidelines for Recovery-Oriented Behavioral Health Care” that include instructions on participation, promoting access and engagement, continuity of care, iden-tifying barriers, and individualized recovery.

In 2006, a Michigan Administrative Rule change went into effect to add four new licensing categories including case management, early interven-

OPEN MINDS — July 2009

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care to protect the intended victim against the danger. Tarasoff created a legal duty, not to the caregiver’s patient, but to a patient’s potential victim. The duty owed by a caregiver to a potential victim created in Tarasoff has been adopted in most states.

In Arizona, for example, Hamman v. County of Maricopa (1989) acknowledged that a caregiver’s duty to prevent a third person from harming another could arise where a “special relationship exists between the [caregiver] and the third person which imposes a duty upon the [caregiver] to control the third party’s conduct.” In Hamman, a mother and stepfather brought their adult son to an emergency room, where they described the son’s behavior and violent conduct to an attending psychiatrist, indicating that they feared he would kill some-one. The psychiatrist prescribed medication, not realizing that he had previously prescribed the same medicine but the patient refused to take it. The doctor further failed to review medical records which reflected that the patient had expressed jealousy towards his stepfather and had a history of drug abuse. After the son went home, he killed his stepfather.

The Arizona Court stated that because the mother and stepfather lived with the son, it was the psy-chiatrist’s legal duty to protect them from harm. The Court held that they “were readily identifiable persons who might suffer harm if the psychiatrist was negligent…” However, the courts in both Hamman and Tarasoff were careful to recognize that the legal duty to protect the third party from a patient’s behavior arises only when the victim is ‘readily identifiable’ and uniquely foreseeable to the caregiver.

Many states have implemented statutes attempting to clarify and limit the responsibility of behavioral health providers for breach of the legal duty to protect third parties from harm caused by a person receiving behavioral health services. These laws emphasized that the existence of the legal duty owed by behavioral health provid-ers to protect third persons from harm requires the victim to be ‘readily identifiable.’ Courts and state legislatures did not want to impose upon behavioral health providers a duty to protect the entire public from all harm caused by their patients.

The Tarasoff legacy, however, was not so easily implemented. Courts and state legislatures did not want to impose upon behavioral health providers a duty to protect the entire public from all harm caused by their patients. How does a behavioral health caregiver determine that a consumer’s behavior poses the risk of harm to a readily identifiable person? Typically, courts state that the risk of harm must be “immi-nent.” The term “imminent,” however, is not a scientifically-grounded or meaningful term. In stark contrast, the legal system—based on the premise of blame and fault—is more black and white. In the context of the Tarasoff legacy, it transforms behavioral health providers into victims for not using their talents to predict and prevent violence from occurring.

Of the 60-plus medical negligence claims defended by R. Kolsrud— many of which were reviewed by Don Fowls, M.D.—none of those involving violence against a third party were dismissed for lack of

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The emergence of the recovery model in policy and practice poses some unique challenges for behavioral health professionals. The very prin-ciples that facilitate consumer autonomy are in conflict with the current interpretation of pro-fessionals’ obligation to protect the public from harm. This article examines such conflicts.

The Recovery Model is a Policy DecisionRecovery is not a linear process. The person with mental illness falters, relapses, regroups, and starts again. The factors most commonly associated with success in recovery are medi-cation, community support/case management, self-will/self-monitoring, vocational activity (including school), and spirituality. Each person disabled by mental illness recovers from their illness by shifting the focus of their attention from their illness to getting on with their lives.

The adoption of the recov-ery model by legislatures and courts is a policy deci-sion by our society that

deems the risk of violent behavior by a person with mental illness an acceptable risk. This policy decision means that behavioral health providers cannot be charged with safeguarding the public against random acts of violence simply because the person committing the violence suffers from mental illness. The legal system’s premise of blame and fault does not acknowledge this policy. Instead, the legal system perceives the behav-ioral health clinician as the active agent and the mentally ill patient as the passive agent. This perception is incongruent with the recovery model which empowers the individual patient.

Empirical studies reveal that there is a significant scientific gap between the best clinical practices to predict “violence” and the demands of the law that the prediction of “violence” meets its legal standard. The scientific goal of prediction and the legal goal of blame and fault in individual cases are not the same. A risk assessment tool that yields accuracy at rates one step above chance may have tremen-dous value in the scientific community (or in Las Vegas). However, the inaccuracy of the assessment tools for dangerous behavior does not carry the day in the legal system.

Do Professionals Have a Legal Duty to Protect Third Parties From Injury by Patients?When a behavioral health patient commits a violent act and injures a third person, is the behavioral health provider liable? The landmark case defining the legal duty of a behavioral health provider to protect others from harm committed by their patient is Tarasoff v. Regents of University of California (1976). The Tarasoff court ruled that when a psychiatrist determines—or through use of violence assessment tools should have determined—that a patient presents a serious danger of violence to another, the psychiatrist incurs a duty to use reasonable

Knowing the Professional Risk of the Recovery Model:Policy & Legal Precedents Can Be at Odds

The goal in the legal arena is to assess blame and fault in

individual cases, and behavioral health providers are held

accountable based upon the perception that the behavioral

health provider has the ability to predict violence and prevent it

from occurring.

Russell A. Kolsrud

Don Fowls

OPEN MINDS — July 2009

www.openminds.com 7

I n d u s t r y A n a l y s i slegal duty to protect a third party from harm. In each case, the ques-tion of whether the behavioral health provider should have foreseen the violent act against a potential, identifiable victim was deemed a question to be determined at trial.

Assessing the Risk of ViolenceThere is no reliable empirical evidence that a behavioral health provider is capable of predicting violent behavior over the course of a patient’s life. Although assessment tools are available that help identify populations more likely to be violent, there is no evidence that can predict the specific risk of violence for a given individual. So how does a behavioral health care provider comply with the Tarasoff duty to protect a third party from harm? Are providers forced to flip a coin with ‘involuntary’ treatment on one side and ‘voluntary’ treatment on the other?

Contemporary risk assessment tools for violence focus on the conditions and circumstances in which persons with mental illness are at risk of committing violent acts. A project known as the McArthur Violence Risk Assessment Study identified specific risk factors to assess the potential for persons with mental illness to commit violent acts. Assessment fac-tors have been organized into categories including personal factors (e.g., demographics, impulsiveness and anger); historical factors (e.g., family history of violence, a history of violent acts); contextual factors (e.g., perceived stress, available means of violence); and clinical factors (e.g., symptoms, diagnosis, substance abuse, type of treatment).

A clinician’s assessment decision is influenced by the number and type of risk factors that are present, in addition to the intensity and severity of a patient’s symptoms and behaviors. In essence, the ultimate determination is subjective and varies from clinician to clinician. The provider’s skill and ability to predict violence is examined under the law’s malpractice criteria of conformance to a standard of care. The dilemma created is that the law applies standards to skills that do not exist. In Tarasoff II, Justice Mosk recognized that the application of legal standards “will take us from the world of reality into the wonderland of clairvoyance.”

The Recovery Model & the Legal System CollideIn the legal arena, judges and juries render decisions after a violent act has already been committed. The goal in the legal arena is to assess blame and fault in individual cases, and behavioral health providers are held accountable based upon the perception that the behavioral health provider has the ability to predict violence and prevent it from occurring. Questions of ‘readily identifiable’ victims and ‘imminent’ threats are left for the jury to decide. There are two likely “collisions” of the legal system: hindsight bias and the stigma of mental illness.

Collision 1: Hindsight Bias. In the context of a lawsuit against behav-ioral health providers, hindsight bias overwhelms clinical judgments of predicting behavior. Hindsight bias is the tendency for persons (lawyers, judges, juries) with outcome knowledge (injury and death) to exaggerate their ability to predict the inevitability of the tragic event. It is a person’s tendency to focus on a given outcome and to interpret antecedent behavior or events in a backward processing mode that confirm the outcome. This tendency explains all facts as leading to the known outcome and ignores the reality that, prior to the known event, other outcomes were possible and even just as likely.

Lawyers, judges, and juries overestimate both the likelihood of the known outcome and the ability to foresee the outcome. Fischhoff, in his study, concluded that the participants in the study exhibited hindsight bias with little awareness of its occurrence because they were unable to consciously avoid the bias when asked to ignore out-come information. Later studies by other psychologists substantiate Fischhoff’s findings.

A person’s tendency to focus on a given outcome and interpret anteced-ent events backwards is the same cognitive logic plaintiff lawyers use to analyze potential lawsuits. This process interprets antecedent behavior backwards. The lawyer then presents the hindsight story to the jury with the tragic event as the focal point of the case.

Hindsight bias is a conscious cognitive strategy, because upon receipt of outcome knowledge, lawyers, judges, and juries immediately assimilate it with what they already know about the event in question. The retrospec-tive fact-finder consciously attempts to make a coherent whole of all the facts about the event. During this mental thought process, the fact-finder cognitively rewrites the story “so its beginning and middle are causally connected to its end.”

If, instead, the lawyer, judge, and jury could set aside the known outcome of the patient’s behavior, and reconstruct the conditions under which the behavioral health provider exercised foresight prior to the incident, the plausibility of alternative outcomes is substantially increased.

Collision 2: The Stigma of Mental Illness. Are persons with mental ill-ness more likely to commit violent acts against third persons than the general population? People in our society including our legislatures and judges believe a strong correlation exists between mental illness and vio-lent behavior. Statistically accurate surveys of the population show that the stigma of mental illness is prevalent throughout society; three quarters of surveyed participants view people with mental illness to be violent toward others. This perception manifests deep-seated stereotypes and prejudices about persons with mental illness.

Judges and juries are also burdened by this stigma. They believe that peo-ple with mental illness do not recover, will remain a burden on society, and must be taken care of rather than encouraged to become independent, contributing members of our communities. When a person with mental illness commits a violent act, the immediate reaction of the average per-son is to exclaim, “What is a paranoid schizophrenic doing walking the streets in our town?” The reaction of the average citizen is to blame the behavioral health care provider. Accordingly, legal decisions that are sup-posed to be based on laws are instead significantly based on false beliefs that persons with mental disabilities are inherently dangerous. This belief coupled with hindsight bias severely handicaps the recovery model’s pub-lic policy of consumer independence and control of one’s own life.

Can the Recovery Model Survive the Legal System?The Tarasoff rule is nearly universally accepted by the courts and pro-vides the basis by which mental health professionals are trained. Similar decisions strike a balance between the rights of the mentally ill and the interests of non-patients in avoiding physical harm. Most trial courts, however, find it impossible to apply this principle. Behavioral health providers wishing to avoid lawsuits by random, unidentifiable victims of violence may more frequently resort to involuntarily treating consumers. Such a result is contrary to the policy decisions made by our courts and legislatures that persons with mental illness can live in society as func-tioning human beings. It runs counter to the substantial data that shows persons with mental illness are not inherently violent or more likely to commit violent acts than anyone else in our society. Such a result is also contrary to society’s policy decision that the risk of violent behavior by a person with mental illness is an acceptable risk, given the alternative of depriving a person of their independence and human dignity.

By Russell A. Kolsrud, Clark Hill PLC, Telephone: 480-684-1102; E-mail: RKolsrud@clarkhill.com

& Don Fowls, M.D., Consultant, Clark Hill PLC, Telephone: 480-970-9097; E-mail: DJFowls@aol.com

OPEN MINDS — July 2009

www.openminds.com8

It appears that 2009 is the year of the electronic health record (EHR) in behavioral health and social services—or at least the year when most organizations decide that it is finally time to plan when and how to implement an EHR. Whether your organization is purchasing a new software solution to do this, or simply enhancing the use of a current software application, the process is both time-consuming and expensive.

While many in the field are focused on making sure that they have the right software and can afford to implement it, I’ve noticed in my con-sulting practice that there are a number of additional things we should be doing to prepare for electronic health records that have nothing to do with the EHR software itself. A number of these have to do with an organization’s current technology and staff support operations. I would like to share seven tips for preparing these two aforementioned areas for the inevitable EHR implementation process:

Upgrade your technology infrastructure.Plan the purchase of any additional hardware to support your EHR plans.Determine what mobile solutions you are going to use for fi eld-based staff members.Ensure that you will have 24/7/365 access to the EHR.Put formal Help Desk operations into place to support all system users.Assess and develop your staff’s computer and typing competencies.Formalize the process for training staff in using EHRs.

Upgrade your technology infrastructure. Chances are that your current technology infrastructure will need to be upgraded to support all of the additional staff users as well as the EHR data. Work with your software vendor to make sure that you meet and exceed minimal requirements for file servers and individual workstations. Ensure that both the connectiv-ity between system components and internet access are fast and easy for staff. Infrastructure requirements here will vary significantly between tra-ditional client-server software installations—where you have the software installed at your sites—versus software-as-a-service (SaaS) or application service provider (ASP) models, where the vendor hosts the software from one of their own physical sites.Plan the purchase of any additional hardware to support your EHR plans. In addition to your overall technology infrastructure, you will probably need to purchase or upgrade a number of additional hardware devices. This may include document scanners and other scanning technology, printers, signature pads (for consumer electronic signatures), as well as microphones and other voice recognition technologies.Determine what mobile solutions you are going to use for field-based staff members. You are likely to need additional hardware for staff that access the EHR while working in the community and in consumer resi-dences. This may include a number of laptop computers or other portable devices as well as Internet access via wireless cards or cellular phones. Some vendors do offer a ‘disconnected’ database option where you can sign out EHRs onto a laptop and synchronize them with the main system later, thus eliminating the need for Internet connectivity but posing a dif-ferent set of privacy and security challenges.Ensure that you will have 24/7/365 access to the EHR. A big step for most organizations is ensuring that their management information system

1.2.

3.

4.5.

6.

7.

S u r v i v a l o f t h e S m a r t e s t

is available at all times so staff have access to the electronic records to provide care. Preparation here includes not only ensuring the integrity of the technology infrastructure, but building in redundancies for system and data access. Organizations should have comprehensive, test-driven disaster plans in place and these may include data replication sites (in additional to routine data back-ups), duplicative or alternate connectivity options, and plans for access to critical electronic health record data in the event of complete loss of access to system data for a period of time.

Put formal Help Desk operations into place to support all system users. While most organizations have some process in place to address man-agement information system requests and questions, it is essential that you operationalize formal Help Desk functions, available at all hours that staff is at work. Usually this means centralizing all Help Desk calls to one place and ensuring reasonable response time to questions and issues that arise. A number of inexpensive third-party software products (some web-based) can help you in monitoring Help Desk calls, ensur-ing timely responses, developing database of answers to common Help Desk questions, and analyzing and managing call trends.

Assess and develop your staff’s computer and typing competencies. Before you delve into the detailed process of implementing electronic health records, you can begin by assessing and developing staff’s skills—Are they already comfortable with using computers and soft-ware? Are they familiar with standard features in Microsoft Windows-based applications? How adept are their typing skills? It is important to not only assess skill sets, but to employ plans to develop these skills before staff have to undergo training for EHR software operation itself. Most organizations are using a combination of third-party software or web-based products for typing skills assessment and training in addi-tion to offering a number of basic computer skills training sessions. Additionally, it is important to integrate these assessment and training processes into your human resource operations for hiring, evaluating, and developing staff.

Formalize the process for training staff in using EHRs. Here you will need to make certain that you not only develop a plan to do initial train-ing for your staff on how to use the electronic health record software, but also for standard training for all new staff hires as well as continued ‘refresher’ and new features training for current staff. Most organiza-tions are also finding that they need to build a computer training lab if they don’t already have one, typically with 12 to 25 computer worksta-tions and projection equipment.

There is certainly a lot more to the process of implementing an EHR, from ensuring that you have the software you need, to addressing clini-cal forms consolidation, from shifting to recovery models of documen-tation, to overall workflow changes. Nonetheless, these seven tips are a good starting point. Good luck!

By Joseph P. Naughton-Travers, Ed.M., Senior Associate, OPEN MINDS

Telephone 717-334-1329; E-mail: jnt@openminds.com

Getting Ready for Electronic Health Records:Technology & Staff Support Infrastructure Tips to Get You Started

Joseph Naughton-Travers

For Further Information on EHR Implementation

Guidelines for Successful Implementation of an Electronic Health Record System. (March 2009). Naughton-Travers, Joseph. OPEN MINDS Circle Library. Available: www.openminds.com/circlehome/eprint/indres/031209guidelines3.htm.

OPEN MINDS — July 2009

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S c i e n c e t o S e r v i c e

Annual Costs of Bipolar Disorder Top $12,000:Treatment of Comorbid Conditions Around 70% of Annual CostsA 2008 study, “Treatment Costs and Health Care Utilization for Patients with Bipolar Disorder in a Large Managed Care Population,” by Guo and other researchers, found that comorbidities accounted for 67% of per patient treatment costs and the mean annual cost per patient totaled $12,797; both charts below comprise this aggregate figure. Typical considerations of the impact of bipolar disorders on the individual and society rely on estimates of burden that were generated in 1995. However, the 2008 study (and others) reflect the debilitating personal nature of the disorder and the com-plexities of treatment created by the prevalence of associated comorbidi-ties. Bipolar disorder presents a complex and changing clinical face that complicates the course of treatment and significantly impacts the costs for all involved: the individual, family, payer, and society. Current cost studies provide insight into the distribution of direct treatment costs among payers.

In a study of Medicaid patients, Guo and others also found a similar treatment cost breakout of 30% for costs directly attributable to bipolar disorder and 70% for treatment of comorbid disorders. Multiple studies have examined the prevalence of comorbidities, finding ranges of associa-tion with substance abuse alone of six percent to 69%. Research provides a picture of bipolar disorder treatment that is complicated by comorbid psychiatric and medical conditions, but indirect costs associated with the disease—which are a major contributor to its overall economic burden—are not always recognized nor factored into cost containment considerations. Both aspects have important implications for treatment efficacy. Bipolar disorder involves a lifetime course of care, but it is an episodic disorder that can interrupt patient and provider care interactions. Controlling disease costs implies a level of adherence to treatment protocols that is difficult to achieve—non-adherence rates among bipolar patients average around 40%.

Only one study provides an estimate of direct and indirect cost of illness based on disease prevalence: Wyatt and Henter’s 1995 “An Economic Evaluation of Manic-Depressive Illness—1991.” One other comprehen-sive study exists, but it is conceptually and methodologically different; estimates are derived for the number of new cases in the study year, 1998, and cannot be compared to the Wyatt study. The Wyatt and Henter study found that the costs associated with bipolar disorders totaled $45.2 billion

(1991 values). Most of this cost ($37.6 billion) is accounted for by indirect costs related to reduced functional capacity and lost work. Direct costs—defined as expenditures for inpatient and outpatient care, which are treatment related, as well as non-treatment-related expenditures such as resource use of the criminal justice system—totaled $7.6 billion.

Bipolar disorders affect as many as 4.4% of the adult U.S. population; with prevalence by subtypes estimated at 1.0% for Bipolar I Disorder; 1.1% for Bipolar II Disorder; and 2.4% for subthreshold bipolar disorder. Bipolar disorder strikes individuals when young (average age of onset ranges from 18-22, depending upon the type) and is ranked by the World Health Organization as seventh in terms of overall disease burden. Surveys con-ducted by the National Depression and Bipolar Support Alliance found that individuals with bipolar disorder reported that correct diagnosis lagged onset by as many as ten years, with only one in four receiving an accurate diagnosis in less than three years. Patients often present themselves for treatment during a depression phase, which can contribute to delays in effective clinical treatment if misdiagnosed as unipolar depression.

Clinical treatment—and its cost—is further complicated by the high rates of psychiatric and medical comorbidities associated with bipolar disorders (on the psychiatric side, anxiety disorders, substance abuse, and personality; on the medical side, hypertension, diabetes, and obesity). The undeniable complexity of the clinical face of bipolar disorder underscores the need to integrate physical and mental health treatment and to screen and treat comorbidities. The implementation of mental health parity (par-ticularly in regards to increased access and funding for treatment of sub-stance abuse) could hold the promise of advances in integrated treatment approaches and be an important step in improving outcomes and disease management.

By Laura Morgan, Consultant, OPEN MINDSTelephone 717-334-1329; E-mail: lmorgan@openminds.com

Laura Morgan

OPEN MINDS — July 2009

www.openminds.com

I n n o v a t i o n W a t c h

10

Expand Cognitive Functioning Via New Technologies: Key Considerations for Trying These ‘New Wave’ Technologies in Your Current Model

The issue of technologies for improving consumer cognitive functioning has become an increasingly hot topic in our field. Cognitive functioning has long been a clinical issue for consumers with serious mental illness and is a growing issue for the aging U.S. population that wants to continue to reside in their own homes as opposed to more institutional settings. While there have always been efforts to understand and improve cognitive

functioning, technologic research and communication advances have created a leap in potential and progress in this area.

As presented in an article entitled “Emerging Technologies and Cognitive Disability,” from the 2004 issue of Journal of Special Education Technology, “Many persons with cognitive disabilities utilize assistive technologies to enhance functioning in daily liv-ing activities...” Furthermore, according to SharpBrains, a market research company focused on the brain fitness and cognitive health market, consumers, seniors’ communities, and insurance providers drove year-on-year sustained growth, from $225 million in 2007, to $265 million in 2008. Further, SharpBrains predicts that revenues may reach between $1 billion to $5 billion by 2015, depending on how well important problems—like public awareness, navigating claims, research, health culture, lack of assessment—are addressed. Possible key customer groups purchasing brain fitness applications include individual purchasers (particularly those over 50), insurance companies and health care providers ranging from hospitals to nurs-ing homes and retirement communities, school administrators (helping children with learning disabilities), and some large companies.

Nintendo has shipped millions of copies of its brain stimulation prod-uct—Brain Age—globally since its launch in 2005. Less visible is the growing number of developers that are bringing brain fitness products with more solid clinical validation to the market.

Key Questions to be ConsideredWith all of the progress occurring in this arena, it is important to con-sider the potential these new cognitive enhancement technologies have to enhance treatment and service delivery. Some facets to examine include diagnostic functionality, coverage, cost, and outcomes. With a stronger understanding of what these technologies can do, you can then begin to consider what they can do for your organization’s ser-vice delivery.

Do these services and products perform diagnostic functions? Some of the emerging cognitive treatment technologies do support diagnoses, but are meant to be used in conjunction with other methods. During an interview with Amie Moreno, Brain Resource’s San Francisco account director, she emphasized that Brain Resource applications look at the person—not the disease—and that their applications are evidence-based “decision support” tools that can assist professionals in their own clinical assessments, evaluations, and decisions. Brain Resource is an “integrative neuroscience” company which began building the brain database 25 years ago.

Do some of the applications constitute treatment? None of the com-panies have made a claim that their applications constitute treatment.

In a July 2008 press release regarding their relationship with Brain Resource, Greg Bayer, Ph.D., chief executive officer of OptumHealth Behavioral Solutions, positioned its applications as providing support to aid in treatment. It would be instructive to ask health and behav-ioral health providers if they believe these applications constitute treatment and, if so, if they consider it a threat.

Do these services constitute a covered benefit? Use of cognitive treat-ment technologies do not appear to be included in health plans’ cover-age. So far it appears that companies are primarily targeting sales to individual purchasers, and some health care provider organizations such as nursing homes, as well as EAPs. Although this issue has not been fully addressed, one entity—Posit Science—is working with a small health plan in Florida. If brain and cognitive fitness technolo-gies are to be positioned as a covered benefit, hurdles to overcome include the determination of medical necessity; the presentation of a diagnostic and procedure code; and whether the application is deemed experimental.

Are the technologies cost-effective? The research is not yet published, but supports the cost effectiveness of these new technologies. During an interview with Eric Mann, vice president of business development for Posit Science, he indicated at least one study has shown Posit Science is cost effective, creating potential for both quality of life and financial return on investment. Posit Science works with a global team of scientists to build scientifically validated, non-invasive programs for improving brain health.

In a MarketWatch interview on May 13, 2009, Dr. Eugene Baker, the vice president of EAPs for OptumHealth Behavioral Solutions stated that, “Improving brain health can result in less ‘presenteeism,’ the ten-dency to be at work but distracted and not able to focus. If you look at disability costs, absenteeism and presenteeism account for most of the medical costs, and that’s a good reason for employers to be focused on brain health.” From a third party reimbursement standpoint, it is reasonable to question whether health insurance underwriters would apply a discount to a health insurance premium when pricing services for groups that include brain fitness (or brain decision support) appli-cations within their benefit package.

What are the outcomes? It is too early to tell, but there is reason to be optimistic that the emerging cognitive functioning technologies have a positive effect. A recent published study of a Posit Science application was conducted by researchers at the Mayo Clinic and the University of Southern California. The study showed that participants in the brain fitness program more than doubled their brain processing speed, had improvements in memory and attention equal to about 10 years, and reported significant improvements in everyday activities. These changes were clinically significant and were greater than the changes in the control activity group, which were not clinically significant. While speaking with Mr. Mann about a schizophrenia application, he said that early study results show an improvement in the cognitive functioning of those who suffer from schizophrenia. In a March 16, 2009, issue of Biomedicine, Mary Furlong, Ed.D., a leading authority on aging and consumer technology, stated, “Consumers should look for products with published studies showing the product worked, and should be wary of general claims that a product stimulates the brain

Bruce Gorman

OPEN MINDS — July 2009

www.openminds.com 11

I n n o v a t i o n W a t c hwhen there is no published study of that product.” In regards to alter-native market segmentation, separating those companies that have data to support their efficacy versus those who do not will be a crucial dif-ferentiator for the health insurance market.

Implications for Purchasers, Providers & ConsumersIt will be useful to track the extent to which technological entries promising “new developments” that can assist or augment cognitive functioning can actually fulfill their potential to improve the health and well-being of individuals in their everyday lives. This industry, however, will have to face some daunting challenges, particularly in the area of consumer and provider acceptance, especially with all of the issues surrounding third-party payment and incorporation in the health care delivery and financing system. Some key implications of these innovations and questions to contemplate include:

Whether health and behavioral health providers will embrace these tools and incorporate them into their practices and systems is crucial. It is important to remember that the traditional behavioral sector has been decidedly “low tech.”Whether and to what extent public and private purchasers and payers will reimburse for these tools.To what degree that these activities lead to self-diagnoses and treatment.Whether a value proposition and message be crafted to encourage adaptation, continued testing, and acceptance.

With that said, innovation is to be encouraged, supported, and applauded. However, the practical application by—and acceptance in—the complex health and behavioral health system is equally impor-tant.

By Bruce Gorman, Senior Consultant, OPEN MINDSTelephone 717-334-1329; E-mail: bgorman@openminds.com

For More Information on Emerging Treatment Technologies

Innovations to Watch: Consider the Market Implications in Your Next Strategic Plan. (April 2009). Oss, Monica. OPEN MINDS, The Behavioral Health & Social Service Industry Analyst. Available: www.openminds.com/circlehome/eprint/2009/040109/040109i.htm.

New Developments & Service Opportunities in Neurotech & Cognitive Retraining Technology. (2009). Sumner, Mona & Jon Gjersing. OPEN MINDS Circle Library. Available: www.openminds.com/circlehome/indres/040409neurotechrimrock.htm.

NIH Launches Challenge Grant Program With Stimulus Funds; NIMH Projects Included. (March 2009). OPEN MINDS On-Line News. Available: www.openminds.com/circlehome/eprint/omol/2009/033009news3.htm.

The Treatment Technology Showcase: Disruptive Innovation in the Behavioral Health Field. (2009). Oss, Monica. OPEN MINDS Circle Library. Available: www.openminds.com/circlehome/eprint/indres/040709oss.htm.

Use of Brain Imaging, Mapping, and Cognitive Tools. (2008). Ruksys, Vid. OPEN MINDS Circle Library. Available: www.openminds.com/circlehome/eprint/indres/030209neuronetics.htm.

Leading Tools for Cognitive Enhancement

Brain Resource,Brain Resource Ltd.; IBM Business Partner

www.brainresource.com

Posit Science, Posit Science Corporation

www.positscience.com

Brain Age,

Nintendowww.brainage.com

Dakim BrainFitness,

Dakim Brain Fitnesswww.dakim.com

FitBrains,

Vivity Labs, Inc.www.fitbrains.com

CogniFit Personalized Brain Fitness Programs,

CogniFit, Inc.www.cognifit.com

Lumosity Brain Training Games,

Lumos Labs, Inc.www.lumosity.com

Neuro Virtual Reality Therapy,The Virtual Reality Medical Center

www.vrphobia.com

Low Energy Neurofeedback System (LENS),

The Brain Resource Centerwww.brainfitness.com

Adaptive Computerized Cognitive Training,

New England Cognitive Centerwww.cognitivecenter.org

Core:Tx® Rehabilitation Tool,Performance Health Technologies

www.kineteksystems.com/product-pages/PHT-CoreTx-

details.html

Audio-Visual Entrainment (AVE)The Center for Cognitive Enhancement

www.enhanceyourbrain.com

VirtualGalen Virtual Reality & Avatars for Autism,

Galen Brandtwww.virtualgalen.com

Play Attention,

Unique Logic and Technologywww.playattention.com

OPEN MINDS — July 2009

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M a r k e t U p d a t e

VOLUME 21, ISSUE 4163 YORK STREET, GETTYSBURG, PENNSYLVANIA 17325-1933TOLL FREE: 877-350-6463 , 717-334-1329, FAX: 717-334-0538

E-MAIL: openminds@ openminds.com WEB SITE: www.openminds.com

PUBLISHER – Monica E. OssEXECUTIVE EDITOR – John F. Talbot, Ph.D.

MANAGING EDITOR – Carly J. Hale

OPEN MINDS, The Behavioral Health & Social Service Industry Analyst (ISSN: 1043-3880) is an independent newsletter meeting the needs of the behavioral health and social service field. OPEN MINDS is published monthly as part of premium membership in The OPEN MINDS Circle, a package of information services that includes the monthly newsletter and weekly On-Line News. Copyright 2009 by Behavioral Health Industry News, Inc. All rights reserved. Reproduction in any form without the consent of the publisher is strictly forbidden.

Annual subscriptions to OPEN MINDS are available as part of premium membership in The OPEN MINDS Circle for $325. Multiple subscription rates are available upon request. To order, call toll-free at 877-350-6463, 717-334-1329, e-mail: openminds@openminds.com, or order on-line at www.openminds.com/premiumcircle.

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The Behavioral Health & Social Service Industry Analyst

Moving at glacial speed—and with glacial force—Washington is moving on a parallel path to health reform in shaping the future vision of a national electronic health records system. Here is an update from the OPEN MINDS team on key developments to keep in mind in your planning process.CCHIT Pushes Back Timelines for 2009-2010 Certification Program; Will Adapt to ARRA FirstOn June 1, 2009, the Certification Commission for Healthcare Information Technology (CCHIT) said it is transitioning its electronic health record (EHR) certification program timelines to adapt to the American Recovery and Reinvestment Act of 2009 (ARRA) requirements and the upcom-ing work of the Office of the National Coordinator and its Advisory Committees. CCHIT has submitted the 2009 criteria to the Health Information Technology Standards Committee for review. Feedback is anticipated by August 26, 2009; CCHIT will address the feedback before accepting applications for the 2009-2010 certification programs. The delay will not affect the behavioral health EHR certification; it is on-track for the scheduled release in 2010.Discussion on EHR Meaningful Use Heats Up: Meaningfuluse.org Launches & HIMSS Suggests Definitions On May 12, 2009, just two weeks after the Healthcare Information Management and Systems Society (HIMSS) submitted its definitions for meaningful use of electronic health records, the Association of Medical Directors of Information Systems and Compuware Corporation launched a new web site, meaningfuluse.org as a forum for health care professionals to discuss “meaningful use” of electronic health records. The web site features news articles, discussions, and polls. Provisions of the American Recovery and Reinvestment Act require the Office of the National Coordinator for Health Information Technology to develop definitions of “meaningful use” of electronic health records for hospitals and for physician practices. The hospital-focused definition will be effective October 1, 2010; and the physi-cian definition will be effective January 1, 2011.GE Healthcare Partners With CDC to Provide Real-Time, Targeted, EMR Public Health AlertsOn April 5, 2009, GE Healthcare announced a partnership with the federal Centers for Disease Control and Prevention to provide breaking public health alerts to physicians via electronic medical record (EMR) systems. The partnership will start a pilot program that will explore the feasibility of creating and integrating actionable alerts with GE’s Centricity® EMR sys-tem based on patient record content using a standard messaging format. The project will determine the EMR’s ability to identify specific patients with risk factors related to the health condition identified in the alert with the goal of enabling clinicians to immediately address the condition.HHS Issues Guidance on Safeguarding Personal Health InformationOn April 17, 2009, the Department of Health and Human Services (HHS) issued its initial guidance on safeguarding personal health information to Health Insurance Portability and Accountability Act (HIPAA)-covered enti-ties, including health care providers and health plans. The guidance outlines the minimum safeguards that HHS expects to require HIPAA-covered enti-ties to use to secure protected health information. In addition, it establishes circumstances in which the new data breach notification rules added to federal law under the Health Information Technology for Economic and Clinical Health Act will require HIPAA-covered entities to notify patients of a breach of security of protected health information.CCHIT Calls for Work Group Volunteers to Support Expanded Certification Program DevelopmentOn March 23, 2009, the Certification Commission for Healthcare Information Technology (CCHIT) opened a 30-day application window for work group volunteers to support its expanded 2009-2010 certification

OPEN MINDS Electronic Health Records Update:The Wheels in Washington Move Slowly but Surely to Shape Health Information Policy

program development. CCHIT has expanded its work to meet the require-ments of the health information technology (HIT) sections of the American Recovery and Reinvestment Act (ARRA) which designated $19 billion for health IT investment. Certification was specified as a key mechanism to ensure that electronic health records (EHRs) adopted as a result of the ARRA funding will provide quality, safety, and efficiency.In February 2009, the CCHIT Board of Commissioners voted to start devel-opment of four programs—Clinical Research, Dermatology, Advanced Interoperability, and Advanced Quality—for launch in 2010. These pro-grams are in addition to two areas previously scheduled for a 2010 launch, Behavioral Health and Long-Term Care. Four other certification programs were identified for launch in 2011: Eye Care, Oncology, Advanced Security, and Advanced Clinical Decision Support. Hospital EMR Penetration Low; Only 1.5% Have Comprehensive SystemsOnly 1.5% of United States hospitals have a comprehensive electronic medical record (EMR) system that is present in all clinical units. About 7.6% have a basic system that is present in at least one clinical unit. About 17% of hospitals have implemented computerized provider order entry for medications.

CMS Delays ICD-10 Implementation Until 2013On March 16, 2009, the Centers for Medicare and Medicaid Services (CMS) confirmed that implementation dates for the tenth International Classification of Diseases (ICD-10) code set would be delayed until October 1, 2013. The ICD-9-CM code sets, developed nearly 30 years ago, will be replaced by the greatly expanded ICD-10 code sets.

By Terry Griffin, Manager, OPEN MINDS On-Line NewsTelephone 717-334-1329; E-mail: tgriffin@openminds.com

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