As the rest of health care rapidly adopts new technological advances and data-use methods, many behavioral health providers are still using paper health records. Case in point: Less than half of behavioral health providers use electronic medical records.

That’s a problem, some warn, because the lack of EMRs could hinder the industry from adopting cutting-edge technologies and innovative payment models requiring digitized data.

In many ways, the slow adoption of EMRs is because the 2009 HITECH Act, which gave health care providers funding to encourage the “meaningful use” of EMRs, did not include behavioral health providers.

Behavioral Health Business sat down with Acadia Healthcare Company (Nasdaq: ACHC) Chief Strategy Officer Andrew Lynch to dive deeper into the need, challenges and future of EMRs in behavioral health. Lynch, Acadia CEO Christopher Hunter and Dr. William Shrank, a venture partner at Andreessen Horowitz and the former CMO of Humana Inc (NYSE: HUM), also recently penned an op-ed on the topic.

Acadia Healthcare is the largest pure-play behavioral health care provider in the U.S. It operated 250 facilities with about 11,000 beds in 39 states and Puerto Rico at the end of 2022.

The below conversation was edited for lengthy and clarity.

BHB: Behavioral health was excluded from the 2009 HITECH Act. How has that stunted EMR adoption?

Lynch: EMRs had been around for many years before meaningful-use incentives came in, and there just had not been much uptake. And once meaningful use came in on the med surg side, you saw this big acceleration. For example, from 2011 to 2015, you saw a 53% increase in non-federal acute care hospital EMR use. This big spike in EMRs was driven by meaningful use.

We didn’t get that on the behavioral health side; correspondingly, you didn’t see that growth. EMRs are very expensive from a software perspective, implementation perspective, and so on.

It’s hard enough for a company like Acadia. We’re investing where we can. And we’ve been public about that. But behavioral health is a very fragmented industry with small players, and it’s tough to implement without those meaningful-use incentives. So, it’s had a hindering effect on EMR uptake.

That’s why you see, depending on which numbers you believe, less than 50% of behavioral health hospitals have an EMR. And the last thing I’ll say about that is, what we are understanding is from talking to different people in the industry, what’s skewed those numbers is a lot of times, the portion of those who do have an EMR, they’re attached to med-surg facilities, and have piggybacked off the med surg. It’s not like you got these freestanding inpatient psychiatric facilities that have EMR very commonly.

EMRs are, in many ways, standard technology for the rest of health care. Does low adoption of EMRs impact behavioral health’s readiness for more advanced technologies, like chatbots, AI and clinical decision-support tools?

Yeah, very much so. When you think about EMRs, on the one hand, you’ve got the basic benefits, like improved patient safety. Medication errors were substantially lower on the med-surg side after EMRs.

Then you’ve got the workflow efficiency and workflow satisfaction aspect, which is so important in a world where there are so few clinicians out there, particularly nurses. We have struggled to recruit nurses in places where we don’t have EMR.

The next horizon is to your point, innovation, whether that’s payment-model innovation, like value-based care. In order to do that, you have to understand data across the whole system, the whole ecosystem, and without EMR, that’s really tough. It limits how quickly we can move to more value-based models.

So many innovative things are going on that rely on the most basic, fundamental-level digitized data. You won’t apply AI to a paper chart that is sitting on a cart.

You briefly touched on how low EMR adoption impacts workforce challenges in behavioral health. Can you talk to me more about that?

We believe, and med surg has shown, that implementing EMRs effectively can improve efficiency and effectiveness. For example, when you have a paper EMR, there’s a physical chart that can only be in one place at once. But then you think, well, there are multiple care team members. You’ve got the psychiatrist, nurse and behavioral health techs. So sometimes you’re waiting, and then there’s handwriting. Everything takes time.

The other thing is so many clinicians today were either raised on EMRs or trained on EMR, and that’s all they know. Or they’ve transitioned, and they know the difference, and they don’t want to go back. And so, from a recruiting perspective, we believe that EMR is important. It’s not just theoretical. We’ve had candidates walk out of interviews because they’re just saying, ”Oh, you’re still on paper. I’m sorry. I didn’t realize that.”

Despite many efforts in Washington, there has been little movement in legislation pushing behavioral health EMR adoption. Are there any bills or movements in Congress that you are watching related to this?

There’s a bill being developed. It’s not out there yet, but it’s being developed, and that will be the sort of the latest incarnation of trying to get something started in this space. It’s not going to be a giant bill to try to fix everything at once. But it’s something to make some progress.

If you had a magic wand, what would you change to make more behavioral health companies adopt EHRs? 

It’s funny; it’s not a spectacular, grandiose answer. We just want to be treated equally. We’d love to have behavioral health hospitals treated like med-surg hospitals in terms of the meaningful-use incentives that have been so transformative on the med-surg side, and we’re not looking for special treatment.

The Surgeon General called behavioral health the No. 1 public health challenge of our time. We believe behavioral health is driving so many upstream problems. Still, even with that, we’re not asking for some additional special treatment, but we just would love to be treated equally with the medical side.

Value-based care and measurement-based care are big topics. How do you see EHRs driving that future? Can VBC and MBC be done without that technology?

In theory, you can try to do it without it, but in practice, it is very unrealistic. VBC is all about fully understanding the connection between costs and value creation, whether that’s quality outcomes, experience, total cost of care, or some capitated cost of care. Different models will kind of prioritize different things and measure different things.

All of those are challenging without EMR. For example, there are systems now that can help track outcomes, whether it’s experience or so on. As you can imagine, if they’ve been developed recently, they weren’t developed to be done with paper and pencil.

In your experience at Acadia, what are some of the biggest challenges and opportunities to EMR implementation for behavioral health providers? 

Med surg, several years after EMRs became more widespread, did studies. There’s like eight different either meta-analyses or individual studies. Every single one showed that medication errors went down, sometimes up to 50% or more. It’s just amazing to think about how powerful that can be.

I think the labor side is really transformative, too. And it’s something that people don’t think about. But if you put yourself in the shoes of a nurse, trying to pick a place to work, it’s tough to ask them to work on paper.

It just makes it tough on the behavioral health side, but we have so much unmet need. So all that is to say – there’s not just one thing that EMR helps with. It’s the data and, in some ways, the workflow backbone of our hospitals. There’s a reason why the HITECH Act prioritized them so much. And we would just love that behavioral health received the recognition as being important enough to be deserving of the same sort of prioritization that med surg got on this.