PowerPoint Presentation

Series 1: Meaningful Use for Behavioral Health Providers9/2013From the CIHS Video Series Ten Minutes at a Time

Module 4: Menu Objectives and Measures for Behavioral Health

Welcome to the SAMHSA-HRSA Center for Integrated Health Solutions video series Ten Minutes at a Time. This information on how to meet the standards for Meaningful Use and how to select and successfully implement an electronic health record system is organized into brief, convenient modules targeted to Behavioral Health providers. This is Series 1: Meaningful Use for Behavioral Health Providers Module 4 Menu Objectives and Measures for Behavioral Health. The goal of this module is to provide a high level overview of the ten Menu Objectives and Measures from the perspective of the Behavioral Health provider.1Outline Menu Objectives and Measures Overview

Menu Objectives 1 through 10 discussed from the Behavioral Health Provider perspective

We will provide an Overview of the requirements around the Menu Objectives and Measures, and explain the implications for the Menu Objective Exclusion Rules. We will then review each Menu Objective from the perspective of the Behavioral Health provider. 2Overview

Ten Menu ObjectivesEP selects maximum of five from Menu Set of ten ObjectivesMust select one of the two public health ObjectivesRemaining Menu Objectives deferred to Stage 2

Exclusion RuleA Menu Objective may have an Exclusion Rule The EP may meet one or more of the Exclusion RulesFor each Exclusion Rule that applies, the number of Menu Objectives to be met is reduced by oneException if both public health measure exclusion rules can be applied, only one can be used to reduce the total number of required Menu Objectives

There is a total of ten Menu Objectives. The EP selects a maximum of five. Efforts to attain the remaining five are deferred to Stage 2. Combined with the Core Objectives, this means there is a maximum of 20 Core and Menu Objectives that must be met by the EP during Stage 1 of Meaningful Use. That total number is reduced when the Exclusion Rule to a Core Objective can be applied. Menu Objectives have Exclusion Rules, too. But since only five Menu Objectives are to be selected from a set of ten, it can be a bit difficult to determine how the Exclusion Rule is used. If any one of the ten Menu Objectives has an Exclusion Rule that can be applied, this reduces the maximum number to be selected from five to four. If two rules can be applied, the maximum number is reduced from five to three. There is one exception to this. At least one of the two Menu Objectives that concern public health must be selected, but it is unusual for Behavioral Health providers to engage in these particular activities. Providers can apply the Exclusion Rules for both measures, but this will only reduce the number of required Menu Objectives from 5 to 4, instead of from 5 to 3.3

More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/drug-formulary-checks Medicaid Preferred Drug Lists for Mental Health and Substance Abusehttp://www.ncsl.org/documents/health/pdl-2-2012.pdf

A drug formulary specifies the medications that can be prescribed under a particular insurance policy. In many cases, information about side effects, contraindications and doses is also made available. Drugs are organized into tiers with escalating co-pays from the patient. The first tier is usually composed of generic drugs with the lowest co-pay, and is called the preferred drug list or PDL. Subsequent tiers will list more expensive versions of the drug along with higher copays. The cost for a drug not on the formulary is usually the responsibility of the patient. This Menu Objective is often one of the five selected by EPs because it improves the efficiency, effectiveness and quality of prescribing practices.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/drug-formulary-checks

http://www.ncsl.org/documents/health/pdl-2-2012.pdf4

More about this Objectivehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380191/ A Case for Manual Entry of Structured, Coded Lab Datahttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/clinical-lab-test-results

Although this is a Menu Objective, the data that it references are required in order to meet many of the Core Objectives. For example, these data are required for the Continuity of Care Record and the patient Clinical Summary. The certified EHR must be able to accept an electronic file that contains lab test results as structured data, but this is passive functionality. To make it active, an interface is required. EHR business usually charge additional money for the interface. In some cases, the labs that Behavioral Health providers are working with do not accept a particular EHR businesss lab interface, and sometimes they do not want to use any kind of interface at all. The lab also may not want to work with the Behavioral Health provider because they do not have a high-enough volume to justify the expense of implementing the interface. If an interface is not a possibility, this Menu Objective can be used for guidance on getting the lab results data into the EHR using manual entry. Note that a portal into a database with lab results or scanned documents will not meet the standard. The data must be integrated with the patient record. This is covered in some detail in Module 8 as one of the PBHCI grant requirements.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/clinical-lab-test-results

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380191/5

More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-list Population-based Health Care: Definitions and ApplicationsBehavioral Health Integration: An Essential Element of Population-based Healthcare RedesignMore about how to apply population-based health care

The ability to generate lists of patients by specific conditions is an invaluable tool for systemic follow-up, treatment adjustment and relapse prevention. It should become central to the integration of primary and behavioral health care. The certified EHR must enable the provider to select, sort, retrieve and generate these lists not only by problem but also by medication, patient demographics and clinical lab test results. This supports the Meaningful Use goal of analyzing population-based data with an eye to eliminating disparities in health care.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-list

http://www.tmci.org/downloads/topic11_00.PDF

http://www.cahpf.org/docuserfiles/Brown_Levey_Miller_deGruy_2012.pdf 6More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-reminders

More about Provider Communication and Patient Adherencehttp://www.ncbi.nlm.nih.gov/pubmed/19584762

Patient reminders are essential to patient engagement in treatment. But the real challenge for Behavioral Health providers is effective patient / provider communication. Reminders are most effective when communication is solid and the patient is actively engaged. For example, a clinician may assume that the patient is in agreement with the proposed medications and treatment plan, but this may not actually be the case. Some questions to ask are: how do you know that the patient agrees with the diagnosis and prescription?; is the patient convinced of the severity of the diagnosis and need for the medication?; are the potential side-effects enough to cause the patient to question whether the risks outweigh the benefit?; can the patient afford the medication? Family members, friends and peer support specialists can all play a role in helping reminders to be as effective as possible.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-reminder

http://www.ncbi.nlm.nih.gov/pubmed/19584762

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More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-electronic-access More about meeting this Objective in conjunction with Objective 4 re: Patient Remindershttp://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/MeaningfulUse/howcaniprovidepatientswiteaccess.html

Many of the individuals who seek out Behavioral Health services for treatment of a serious mental illness use the Internet. Computers with connections are available for free at public libraries, and via paid services on mobile devices including phones and tablets. One increasingly popular solution for providing patients with timely electronic access to their information is via a secure web-portal. This EHR tool may be used for meeting this Objective but the tool should be checked first for robust functionality.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-electronic-access

http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/MeaningfulUse/howcaniprovidepatientswiteaccess.html

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More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-education-resources More about this Using Motivational Interviewing to Make Positive Changes to Improve Patient Healthhttp://www.integration.samhsa.gov/clinical-practice/motivational-interviewing

Patient education is the process of influencing patient behavior and producing changes in knowledge, attitudes and skills necessary to improve health. The EHR does not itself contain the education resources. It identifies resources appropriate to that particular patient and the provider follows up. For example, the EHR can be configured to identify tobacco cessation information for a patient who uses tobacco, and even referral information to a tobacco intervention Wellness group. For those with a serious mental illness, the patient must be ready for and able to understand the information, which should be presented within a trusting relationship that places the focus on patient empowerment and their right to decide. Motivational interviewing can be a valuable tool in helping patients make positive behavioral changes that support better help.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/patient-education-resources

http://www.integration.samhsa.gov/clinical-practice/motivational-interviewing

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More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/medication-reconciliation Medication Reconciliationhttp://psnet.ahrq.gov/primer.aspx?primerID=1

If the patient is admitted from a referring entity, that entity should be able to provide a Transition of Care Summary (discussed in the next slide). This includes their version of the patients Active Medication List. This information can be entered into the receiving entitys EHR for reconciliation with psychiatric medications. If the Transition of Care Summary is not available, Behavioral Health providers may be able to access the state HIE for the patients Continuity of Care Record, which is required to contain the same data as the Transition of Care Summary.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/medication-reconciliation

http://psnet.ahrq.gov/primer.aspx?primerID=1

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More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/transition-of-care

All types of health care providers, including Behavioral Health, often find that they are providing health care to patients without any verifiable knowledge of the patients recent history. Using the Transition of Care Summary in patient referrals eliminates a great deal of that mystery. It is possible for any provider, even a provider without an EHR, to create and transmit this record. The data can be entered from the patient chart into a .pdf template, and transmitted using NwHIN Direct. Behavioral Health providers should consider developing and implementing a procedure for this, because it will soon become common practice. NwHIN Direct is discussed in more detail in Module 9.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/transition-of-care

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More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/immunization-registries

Menu Objectives 9 and 10 concern the collection and reporting of public health related data. As noted, providers are required to select at least one of the two Objectives for reporting. The Measure 9 Exclusion Rule on Immunizations Registries Data Submission almost always applies to Behavioral Health Providers. In this case, the next step would be to review the second public health Objective 10 on Syndromic Surveillance Data Reporting.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/immunization-registries

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More about this Objectivehttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/syndromic-surveillance-data-submission

The Exclusion Rule for Measure 10 is another rule that almost always applies to Behavioral Health providers. Since selecting either Objective 9 or Objective 10 is required, what is the solution? The standard allows the provider to claim both exclusion rules but this reduces the number of Menu Objectives to be reported by one instead of two, for example from 5 to 4 instead of from 5 to 3.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/syndromic-surveillance-data-submission

13SummaryWhen selecting the Menu Objectives you will attain, you must first determine how many are required for reporting in Stage 1.

Reduce the number of Menu Objectives to be met by the number of Exclusion Rules that apply (exception is Objectives 9 and 10 even if both rules apply only one can be applied towards reducing the total number of Menu Objectives)

Select Menu Objectives that support the implementation of the Core Objectives

Select Menu Objectives that support participation in Stage 2. Transitions of Care play a significant role in this stage so implementing this Menu Objective in Stage 1 supports participation in Stage 2

So, here are the important things to keep in mind. Everyone must select 5 of 10 Menu Objectives. Selecting one of the public health Objectives is required. The number of required Menu Objectives is reduced by one for every Exclusion Rule that can be applied. The exception is when both of the public health Menu Objective Exclusion Rules apply. In this case, the required number can only be reduced by 1, not 2. Determine how many Exclusion Rules apply and reduce the number of required Menu Objectives accordingly. Then consider implementing those that support attaining the Core Objectives.14We Have Solutions for Integrating Primary and Behavioral Healthcare

Contact CIHS for all types of primary and behavioral health care integration technical assistance and training needs

1701 K Street NW, Ste 400 Washington DC 20006

Web: www.integration.samhsa.govEmail:integration@thenationalcouncil.orgPhone:202-684-7457

Prepared and presented by Colleen ODonnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions

Our thanks go to SAMHSA and to HRSA for providing support to the Center for Integrated Health Solutions (CIHS) for this and many other forms of training and technical assistance related to the integration of primary and behavioral health care. Please visit our web site at www.integration.samhsa.gov, email us at integration@thenationalcouncil.org, or just pick up the phone and give us a call at 202-684-7457.

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