Knowledge platform envisions better clinical, operational decisions

When Michael Valentine, former COO at acute-care technology giant Cerner joined Netsmart Technologies as its new CEO in May 2011, many in the field wondered exactly what changes might be in store for Netsmart, which has the largest installed base of EHR customers in the behavioral health field.

In succeeding months, the pattern of changes led by Valentine has become clearer. In August, Netsmart acquired Behavioral Pathway Systems (BPS), the industry benchmarking arm of Centerstone Research Institute, and in September, announced a deal with CRI to collaborate in developing and mining the field’s largest database of de-identified patient data.

Netsmart envisions creating and promulgating cloud based services that will 1) consolidate and continually refine clinical approaches that improve decision-making, treatment, and outcomes; and 2) provide a growing base of benchmark, quality, and performance data that will help provider organizations improve the business of treatment delivery.

While unveiling this vision in an exclusive interview with Behavioral Healthcare magazine, Valentine and other Netsmart executives said that such services are essential to enable behavioral health and human services providers to meet the dual challenges of healthcare reform and re-integrating their specialties with the broader healthcare field. At present, they estimated that behavioral health was “about a decade behind” the rest of healthcare in the development and use of such tools.

Valentine also suggested that clinical standards and benchmarking services for behavioral health could have the kind of impact that that the Premier alliance has had in the broader healthcare field.  This alliance of healthcare organizations is at the center of data-collection and benchmarking efforts that now reach to one in four hospital discharges nationwide.  The participation of Premier alliance members in the six-year HQID (Healthcare Quality Incentive Demonstration) program was so successful that it formed the basis for today’s Medicare’s  Value Based Purchasing (VBP) program, one of three critical requirements for inpatient healthcare organizations under the Affordable Care Act.  

It all starts with data

“Our vision is to use an asset, our large installed base, to define of standardized outcome measures, assessments and benchmarks that customers can use to prepare for accountable care,” says Kevin Scalia, Netsmart’s EVP of corporate development. “We expect that there will be some form of pay-for-performance, but that payments will also be based on whether or not you can prove that you’re improving clinical outcomes.  So, the challenge is to make organization more efficient and improve clinical processes at the same time.

“The acute care side is way ahead of us in this area. There is, for example, wide agreement there on what the best practice is when someone walks into an ER with a stroke or a heart attack, whereas in behavioral health there is little unanimity on what the best clinical path would be for a particular individual,” he continues.

“Our strategy says:  if we’re going to advance the field of behavioral health, we have to greatly improve the clinical content of our EHRs—and those across the industry.  We felt that we could do that today by aggregating the voices of our customers.”  Netsmart did this, he says, by acquiring industry rival Sequest Technologies, along with its customer base and core of skilled clinicians, and by bringing in Denny Morrison, PhD, the former CEO of CRI—another new Netsmart customer—who, Scalia says, combines the skill set of a CEO with a clinician’s sense of “how to deliver improved clinical tools in a way that doesn’t disrupt the clinical workflow.”

Scalia explains that when Netsmart’s search for existing national standards, assessments, or measures among its behavioral health customer base for behavioral health, the company approached Tom Doub, the new CEO at CRI, hoping that CRI’s resources might provide an answer.  They didn’t find one, but they did make an important insight: “We quickly realized that while a major national study might have results from 300 individuals, [Netsmart and its customers] were sitting on an installed base of 20 million individuals,” says Scalia. “We began to think, if we could work with CRI to mine that real-world data, they might well be able to develop all sorts of CDS algorithms that we hadn’t even thought of.”

With that approach in mind, Netsmart began construction of a central database that would allow its customer/users to voluntarily contribute de-identified individual data. At the same time, the company is developing additional methods to monitor and communicate with customer EHRs so that it can “layer on” new clinical information and decision tools incrementally. This, Scalia continues, is the first step in a broader effort to expand database access to a much wider circle of would-be contributors, starting with current Netsmart and BPS customers, but extending to others, such as  academic and other institutions that would contribute data, suggest new decision support algorithms, and new data-mining strategies.

Through a just-announced agreement with Centerstone Research Institute, Scalia adds that “Netsmart has agreed to make CRI the first ones to have access to this new database.  They are going to adapt their predictive models—models already under development through the Knowledge Network—to see if they can better inform treatment decisions being made at the point of care.”

This accumulating knowledge, he says, would then be incorporated into EHR tools that would become available to the treatment community, making possible a level of clinical decision support that is not available today. To meet the business needs of the same organizations, Netsmart acquired BPS, which Scalia said “is already working with another very large and very diverse base of providers.” This, he noted, “would have the immediate effect of making participating organizations more efficient during the period when improved clinical systems are being developed.

CRI: A chance to reach out

Through its new agreement with Netsmart, CRI’s CEO Tom Doub recognized a chance to do two things: get access to a huge new font of data and, potentially, to impact the field of behavioral health with CRI’s predictive analytics much more quickly than CRI could ever do on its own.

“We’ve been fortunate in getting our research effort off the ground, thanks to some major donors, but we recognized that if we were going to create something beneficial, we wanted the benefits to go beyond Centerstone—to the field as a whole,” Doub says. “This relationship is a way to quickly integrate our efforts onto a key technology platform and get it out to people rapidly.”

Doub’s former boss, Netsmart’s Denny Morrison, PhD, agrees.  “Our industry hasn’t been very forward- thinking in its use of data-driven decision making,” he says, noting that “the fundamental premise of bringing better information to the clinician is that the clinician, not the computer, must make the decision.” 

Information at the point of treatment

But Morrison says that developing new clinical supports for clinicians involves several sticky problems.  “Problem 1 is bringing the information to the clinician,” he says.  Problem 2 is more basic: “We’ve never really gotten away from the model of paper records.” To allow for the impact of improved CDS tools, Morrison insists that “we have to accept the fact that electronic records can and must do things that paper records can’t.”  Key to realizing this capability is to present useful knowledge in ways that  “don’t screw up the workflow” but can “change the trajectory of treatment in real time.”  Morrison says that research findings must be converted into “digestible nuggets” of information.  You can’t,” he explains, “send up a system alert that says ‘read this paper’ when the patient is in the room.”

Getting that interaction right will be tricky, he adds, noting “the way we think about the workflow will be as important as the way that we present the information.  We’re looking at all sorts of ways to do that now.”

As the problems of clinical decision support get worked out, the foundation will be in place for another essential step in transforming behavioral health performance and quality. This is the transition from managing individuals to managing, and predicting, the health of populations. This falls into the realm of future-focused structures such as accountable care organizations and health homes.

 “This,” explains Scalia, “is where all of the automation comes together” He suggests that value can come in the form of algorithms that look at a population and determine who is most likely to need care or who, for example, has missed recent visits and may be at risk for quitting meds, relapsing, or ending up in the emergency room.

Anticipating and resolving preventable problems across populations is vital, echoes Morrison. “If you can identify those most in need, and perhaps, send out a case manager to meet them or work with them, you’ll be able to take care of them at a cost of a couple of hundred dollars instead of waiting until it is thousands of dollars for an emergency room visit.”  Morrison adds that he sees behavioral health organizations as ideal for the role of operating health homes because they’re accustomed to reaching out to individuals in the community, something that primary care providers do not ordinarily do.  

Putting it together:  an “EHR agnostic” knowledge platform

Netsmart envisions that the products of all its recent efforts— new benchmarking and evolving clinical decision support products, plus other content and knowledge products—will be hosted in the cloud and available through a series of web services. The products will begin to be available for current Netsmart EHR and BPS customers as early as next spring, with other variants becoming available for subscription use by other EHRs sometime thereafter.  The services would be available not only to behavioral health providers, but to physical health providers too, since these patients might well have mental health or addiction problems that exacerbate their physical problems.

“One way to look at all of this is as part of the natural evolution that happens when you digitize things,” says Netsmart CEO Valentine, who compares the coming evolution of behavioral healthcare to the one that’s already occurred in the rest of healthcare. “Step one is to digitize the information, from paper to a mostly digital environment.  All that data then drives step two, a drive for a lot more reporting and analytics, when you can begin to leverage the systems to enlighten your environment and make better decisions.”  

Noting that the behavioral health field is “somewhere between steps one and two,” Valentine goes on to explain that Netsmart’s planned knowledge platform “targets the space between steps two and three of the process, by offering advanced clinical information to drive better decisions and by providing analytics and benchmarks that will show organizations “what you’re doing differently from others who are successful.”

Then, step three is quick to follow, “Step three happens when you use systems and knowledge to layer on additional evidence and proven practices that drive and sustain good behavior.”  He believes that if technology can be used to “introduce and compare what’s working and what’s not working clinically and operationally, we’ll be doing what the physical health side has been doing for some time now across the entire industry.”