Behavioral Health & Health Information Exchange HIE Industry Perspective

Toria Thompson, Consultant

toria@organizationalpatterns.com

303-746-3161

Organiza(onalPa-ernshumanscale–evolu.onary–valuedriven

Agenda

u  Adding Behavioral Heath Information to an HIE (30 mins) u  Benefits

u  Challenges

u  Examples of Behavioral Health Exchange through an HIE (20 mins) u  Health Current, Arizona HIE

u  Quality Health Network, Colorado HIE

u  CORHIO, Colorado HIE

u  Other Considerations (10 mins)

u  Comments and Discussion (15 mins)

Adding Behavioral Health Information

to an HIE BENEFITS

Patients want providers to know

Supporting Integration of Behavioral Health Care Through Information Exchange, CORHIO, 2012, link

Sharing information matters

“Client was hospitalized for 3 days before receiving methadone treatment, unable to contact provider to verify patient’s story.”

–Prince George’s County Health Department

People of Color & Mental Illness Photo Project; link

Adding Behavioral Health Information

to an HIE CHALLENGES

http://www.mentalhealthamerica.net/issues/state-mental-health-america https://www.thenationalcouncil.org/wp-content/uploads/2013/10/CIHS-infographic.jpg

Prevalence of Mental Illness

Why isn’t Behavioral Health Information More Readily Shared?

u  Not Treated: 56% of people with a mental illness never get treatment so no information exists.

u  Stigma

u  Fear of poor treatment: Patients are concerned about being treated differently when their provider knows about their mental health or substance use issue so they withhold information.

u  Fear information will be misused: Behavioral Health treatment providers have long been champions of patient privacy because they have witnessed the devastation that inappropriate disclosure can cause.

u  Federal and State Privacy Protections: Substance Use Information is protected more stringently than other health information under 42 CFR Part 2. Some State’s also restrict sharing of mental health information.

About 42 CFR Part 2

u  Purpose is to protect the confidentiality of people seeking alcohol and drug treatment and prevention.

u  Administered by the Substance Abuse and Mental Health Services Administration (SAMHSA)

u  Regulations were first enacted in 1975, updated in 1987 and most recently revised to enable more broad information exchange in 2016 (effective March, 2017)

42 CFR Part 2, link

Applicability of 42 CFR Part 2

u  Applies to “Program”: any person or organization that in whole or in part provides alcohol or drug abuse diagnosis, treatment or referral for treatment or prevention; AND

u  “Federally assisted”: receives federal funds even if funds do not pay for substance use disorder treatment services

u  Applies regardless of whether the behavioral health provider is co-located in a primary care practice.

Are they covered by 42 CFR Part 2?

u  Jane receives treatment for her opiate addiction from the detox unit of a large hospital (assume the hospital and its detox unit are “federally assisted”). Is the hospital covered by 42 CFR Part 2?

u  Dr. O’Neill is an addiction specialist working in a community health center that provides all types of health care (e.g., primary care, geriatric care, OB/GYN). Dr. O’Neill treats the community health center’s patients who have substance use disorders, and prescribes buprenorphine for opiate addiction as part of her practice. Is Dr. O’Neill covered by 42 CFR Part 2?

u  Is the community health center?

u  Marla Mathews is a licensed mental health professional employed by Primary Care, LLC. For every new patient she administers a list of universal screening questions for risky substance use. If a patient meets the criteria for a substance use disorder, Marla has a short discussion with them about his/her substance use and, if appropriate, provides a referral for treatment. Marla documents her sessions, including the results of the sessions, in the medical record. May Primary Care, LLC share the patients’ medical records, which include the results of their substance use screenings, with other physicians without getting the patient’s consent?

No

Yes

Yes

Legal Action Center, link

No

There is still a lack of consensus on:

v  If community mental health centers categorically qualify as 42 CFR Part 2 agencies or programs.

v  What information within the EHR is covered under 42 CFR Part 2

v  Only information that identifies someone as receiving substance abuse services, or;

v  All information collected while the patient was receiving substance abuse services

v  Whether it is ethical to share some (mental health), but not all (substance use) of the information

A signed release solves the ambiguity

u  Information is flowing: It is common practice at intake at most behavioral health organizations to obtain a signed release to disclose behavioral health information to specific practices for care coordination. The challenge is that this is mostly handled by fax and is often not available in an emergency.

u  42 CFR Part 2 Update: The latest change to 42 CFR Part 2 allows a release of information to list “All my treating providers” as a general designation.

HIEs can improve efficiency while still honoring a patient’s right to choose

With HIE Before HIE

Examples Behavioral Health

Exchange Through and HIE

•  HEALTH CURRENT

•  QUALITY HEALTH NETWORK

•  CORHIO

HIEs doing bi-directional exchange

u  Arizona, Health Current*

u  Colorado, CORHIO & QHN*

u  Kansas, Kansas Health Information Network*

u  Maine, HealthInfoNet (Mental Health Only)

u  Michigan, Washtenaw County Mental Health & Michigan Care Connect; Michiana Health Information Exchange (Opioid Treatment Providers)

u  New York, multiple

u  Oregon, Reliance eHealth Collaborative

u  Rhode Island, Current Care

* Opt-Out States (patients are automatically opted-in for HIPAA exchange)

Health Current

u  HIE for Arizona

u  200+ Organizations that provide Behavioral Health Services

u  Patients Rights Video regarding Behavioral Health data:

https://healthcurrent.org/hie/patient-rights-process/

u  Exchanging: Behavioral Health Continuity of Care Documents (CCDs), Progress Notes, Crisis Plans, Involuntary Commitment Orders, Risk Assessments, etc.

u  Using Consent built into Mirth HIE Software (same vendor as HSX)

Details of Health Current’s BHIE

Consent: u  Gathered at the point of care

u  Provider can fax or send PDF via sFTP or enter consent via Provider Portal

u  Provider EHR can send consent via HL-7 v2 or CCD interface

u  Legal counsel requires actual signed form to reside in the HIE

u  Workflow is being adapted to latest 42 CFR Part 2 change allowing “All My Treating Providers”

Use Cases: u  Provider can access BH data in an emergency (as defined by 42 CFR part 2)

u  Provider can access via Provider Portal and download consolidated BH CCD.

u  Psychiatric Inpatient discharge summaries sent to downstream providers via results delivery into ambulatory EMRs.

u  Crisis Service Network sends documentation to BH organizations for patients they treat after hours via crisis services workflow.

Quality Health Network (QHN)

u  One of two HIEs in Colorado (other is CORHIO)

u  Two Community Mental Health Centers (CMHCs) provide the majority of outpatient and inpatient behavioral services to the region

u  Exchanging: Behavioral Health Continuity of Care Documents (CCDs) including Progress Notes.

u  Workflow is being adapted to latest 42 CFR Part 2 change allowing “All My Treating Providers”

u  Using Consent built into Mirth HIE Software

Details of QHN’s BHIE

Consent:

u  Patient signs consent at intake with CMHC. CMHC creates a .CSV file with care summary and consent. This .CSV file is transformed into an HL-7 transcribed note and the consent is updated in QHN.

Use Cases:

u  Provider can access via Provider Portal: If provider’s organization not listed on consent, they can “break the glass” to access documents by getting patient consent at point of care and uploading into QHN

u  Delivery into Ambulatory EHR: Replacement for manual faxing of CMHC reports to down stream providers. Currently more than half of the 850+ monthly reports are sent via QHN.

CORHIO

u  One of two HIEs in Colorado (other is Quality Health Network)

u  17 Community Mental Health Centers (CMHCs) provide the majority of outpatient behavioral health care

u  Numerous substance use treatment providers who mostly do not have EHRs

u  Pilot for bi-directional exchange is underway: Choose2Share.com

u  Currently Exchanging CCDs from one CMHC

u  Customized SAMHSA’s Consent2Share open source product for consent

u  Patient Consent Education Video: https://youtu.be/82y4bbnPTtg

Details of CORHIO’s BHIE

Consent: u  Patient entered via Choose2Share.com

u  Consent is from Behavioral Health organization to another health care organization for purposes of Healthcare Treatment

u  FUTURE:

u  Consent as part of Patient Health Record

u  Provider EHR can send consent via HL-7 v2 or CCD interface

Use Cases: u  From Provider Portal (via XCA – Behavioral Health Documents treated like a separate HIE)

u  FUTURE:

u  Routed into ambulatory EHRs

u  Event Notification

u  Emergency (as defined by 42 CFR Part 2)

Behavioral Health OTHER CONSIDERATIONS

Behavioral Health Integration Tools

Cognitive Behavioral Therapy (CBT):

u  Use Case 1: Treatment of chronic illness often necessitates behavioral change. CBT can help patients make the shifts in thinking to help them become more engaged in practices that enhance their health.

u  Use Case 2: Primary care providers can support patients with moderate mental health symptoms by offering online tools to help patients manage symptoms and get to help quickly should they experience a mental health crisis.

u  Tools:

u  MoodGym: Treating Anxiety and Depression using CBT

u  Ieso: Therapy at your fingertips

u  MyStrength: The health club for your mind

American Psychiatric Association is currently evaluating the

effectiveness of these types of online tools. Quality and

effectiveness vary widely. (link)

HSX Behavioral Health Subcommittee cautioned use of

these tools to replace more traditionally effective modalities.

Other Behavioral Health Considerations

u  Social Determinants of Health Data

u  Opioid Crisis

u  Tele psychiatry

Comments and Questions

ToriaThompsontoria@organiza*onalpa-erns.com(303)746-3161Organiza(onalPa-ernshumanscale–evolu.onary–valuedriven

Thank you!