What psychologists need to know about Health Information Exchanges

Health Information Exchanges (HIEs) allow health care providers, including behavioral health providers, to securely access and share a patient’s medical information in real time, leading to improvements in care coordination, safety, and quality of care while reducing costs and time needed to transfer records manually.

For example, if a person with mental illness presents to her local emergency room (whether for a related or unrelated health problem), it can be critically important to know what medications were prescribed at her last psychiatric visit, the location of that visit, such as a community mental health center or at a local private psychiatrist’s office, or that she was receiving care from a psychologist two counties away and was recently involuntarily committed. With the use of HIEs, this contextual information is not dependent solely on patient recall and accuracy and can minimize the extent to which patients have to maintain their own medical records whether in paper or digital form to see multiple providers and specialists.

Many psychologists may not be aware that their state has an HIE or that they might one day be required to participate. HIEs are now found in all 50 states, and most states have some type of statutory language that specifically address HIEs as well. States vary widely in whether participation is voluntary or mandatory. States also vary as to whether behavioral health is included. A small number of states have begun specifically requiring the participation of behavioral health providers, such as Connecticut and Oklahoma (Oklahoma psychologists received a last-minute reprieve from the July 1, 2023, start date when the proposed rules did not receive the Governor’s signature).

For psychologists, involvement in HIEs to date has been less robust than other professions, largely due to intentional exclusion from early incentive programs. In 2009, a large piece of federal legislation called the Health Information Technology for Economic and Clinical Health Act (HITECH Act) provided start up and incentive funding to encourage the health care field’s transfer to electronic records. Most behavioral health providers, including psychologists, were excluded from the meaningful user definition under the HITECH Act and, as a result, were denied access to these funds. Consequently, psychologists and other providers—particularly those in small and independent practices—have fallen far behind physicians, medical health care practices, and large health care systems in terms of their move to electronic health records (EHR) and their ability to exchange electronic health data with other systems in a secure manner.

This ability to connect to other systems, made by different manufacturers, is called “interoperability.” The price for participation for psychologists can be high and for some even cost prohibitive. Investing in the software, hardware, and training required to use an EHR system is expensive and time-consuming. Psychologists, especially in small independent practices and those operating in rural and underserved areas, often have low operating margins and limited working capital available to invest in EHR adoption.

An additional barrier to wholesale adoption of EHR has been that federal and state privacy laws recognize that the most sensitive patient data (typically behavioral health and substance use data) should be afforded greater protection from disclosure to third parties (including, but not limited to, payers and other providers) and to patients themselves at times. Many EHR systems are not designed to include the greater privacy protections required by federal and state laws compared to other health data, nor are they equipped to evaluate the interplay between state and federal patient privacy protections. For example, federal laws like HIPAA may take precedence over state laws, but there are certain circumstances where state laws have priority over federal laws.

Despite the valid concerns about privacy and implementation hurdles, it is important to the profession that behavioral health be at the table. Behavioral health is part of health care, and historically when behavioral health has been excluded from legislation, it has hampered the profession. APA is currently involved in providing resources to states, identifying needed data elements for care coordination, clarifying the statutory and legal requirements and frameworks within which to operate, and preparing psychologists and their software partners to be ready to participate in future interoperability requirements. In an effort to support psychologists and ensure that state requirements deal with the sensitivity of mental health records, APA is working closely with its state partners as HIEs roll out.