Health Information Technology and Behavioral Health

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2 Health Information Technology and Behavioral Health Kate Tipping, J.D. Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services Annual Summit on Telehealth Technologies A Forum for Telehealth Innovations National Frontier and Rural ATTC August 26, 2014

3 President Barack Obama Medical information will follow consumers so that they are at the center of their own health care. Consumers will choose providers and hospitals based on clinical performance results available to them. Clinicians will have an individual s complete medical history, computerized ordering systems, and electronic reminders to improve quality of care. 3

4 Today s Behavioral HIT Topics Improving Practice Protecting Privacy SAMHSA s Solutions 4

5 Today s Behavioral HIT Topics Improving Practice Protecting Privacy SAMHSA s Solutions 5

6 Interoperable HIT for Seamless, Integrated, Comprehensive Health Care Mental Health Services Community Services Substance Abuse Treatment Programs Pharmacies, PDMPs Hospitals Consumer Centric Health Information Exchange Insurance Providers Primary Care 6

7 U.S. National HIT Landscape HITECH Act: Large national investment in HIT; largely excludes BH providers. Health Reform & the ACA: Coordinated, integrated, client-centered care; expanded consumer base & transformation of service delivery and payment models; MHPAEA. Privacy and Confidentiality Regulations: HIPAA; HIPAA Omnibus Rule; & 42 CFR Part 2. 7

8 Improving Practice: SAMHSA s Behavioral HIT Strategic Initiative Ensure that the behavioral health provider network, including prevention specialists and consumer providers, fully participates with the general health care delivery system in the adoption of health information technology. Support the behavioral health aspects of the electronic health record based on the standards and systems promoted by the Office of the National Coordinator for Health IT. 8

9 SAMHSA s Behavioral HIT Objectives Increase the involvement of BH organizations and providers in HIT initiatives including Health information Exchanges (HIE), EHRs, and PDMPs. Increase the number of BH organizations meeting meaningful use activities. Address the issues of privacy and security associated with mental illness and substance use disorder treatment. Expand working relationships & collaborations across the public health and health care fields. 9

10 SAMHSA s Behavioral HIT Goals Develop infrastructure for interoperable EHRs, including privacy, confidentiality, and data standards. Support initiatives to develop/expand interoperability between various data systems including HIEs, EHRs, and PDMPs. Provide incentives and create tools to facilitate the adoption of HIT with behavioral health functionality in general and specialty healthcare settings. Deliver technical assistance to State Health IT efforts; behavioral health providers; & and other stakeholders. Enhance HIT capacity, functionality, and accuracy to assess & improve quality-of-care and patient outcomes. 10

11 The Role of Health IT Health Information Technology is an important part of providing integrated treatment by linking between programs, services, and providers. Health IT can help behavioral health providers: Communicate and collaborate between providers and other programs Track the progress of those who leave a program and monitor when and if additional services are needed Reduce redundancy between programs and providers Improve the quality of care Increase access to services and support 11

12 Examples of SAMHSA Behavioral HIT Projects Collaborations with public & private partners to enhance & expand HIT capacity & interoperability. TCE-Technology Assisted Care Grants. Grants for OTPs to adopt or upgrade to certified EHRs. Incorporating HIT into SBIRT. Using new media to prevent Substance Abuse & HIV/AIDS. Mobile App Challenges. Open source module development. 12

13 Using HIT to Increase BH Client Engagement HIT has tremendous potential to increase the engagement of BH clients in their own care. Provide individuals with health information tailored to their own risks and health literacy Provide links to community and online resources Provide tools to support self-care & shared decision making Goal setting and tracking Supporting adherence Interfacing with mobile health tools 13

14 Applying HIT BH Performance Measures HIT BH performance measures help providers answer the questions: Do we have a clear understanding of our goals? Are our goals measurable and evidence-based? Are we reaching the right populations? Are client and treatment properly aligned? How do we define & demonstrate success? 14

15 Behavioral HIT Stakeholder Engagement SAMHSA held three HIT Regional Forums: Participants were from 50 states and U.S. territories. Objective: facilitate the integration of standardsbased HIT within the behavioral health field. SAMHSA also met with various stakeholders regarding behavioral health electronic records & performance measures (APA, ASAM, NAADAC, NASADAD, NASMHPD, etc.) 15

16 Behavioral HIT Stakeholder Concerns Matching evolving business practices with evolving trends in treatment. Interoperability (e.g, compatibility of legacy systems w/newer systems). Not having the ability to receive Meaningful Use incentives. Smaller practices lack the funds to be able to successfully implement EHR. Lack of resources to properly educate staff on the proper use of EHR. 16

17 Behavioral HIT Challenges How should HIT systems be designed to control disclosure and re-disclosure of BH sensitive information? How can we ensure that when BH data are shared they are interpretable across providers and by third parties (e.g., researchers, public health, surveillance)? How can BH systems evolve rapidly along with research and changing best practices? How can new technologies take us to the next level of BH care delivery? 17

18 Behavioral HIT Challenges (cont.) How can technologies be used to reduce BH reporting burdens while improving data quality? Minimize data re-entry Harmonize across programs to data elements collected in the normal course of care delivery How can BH systems share information with other service agencies? For example: Criminal Justice Housing and Urban Development Local & Regional Public Health and Social Services Agencies 18

19 Today s Behavioral HIT Topics Improving Practice Protecting Privacy SAMHSA s Solutions 19

20 HIT & BH Privacy 20

21 Confidentiality and Trust In order to achieve any level of systemic durability and success, HIT must be trustworthy and developers and managers must warrant & sustain trusting relationships with all participants, especially the public consumer. Privacy is not an area for compromise Confidentiality should never be a shortcut Security should not be a second thought or an afterthought 21

22 Forced Consent is Not Consent Consent cannot be valid if people can only obtain essential services by providing it. James Willis, British Journal of GP Br J Gen Pract September 1; 54(506): 725 ; 22

23 Privacy & Technology: Partners or Adversaries? Data integration and aggregation, coupled with increased on-line accessibility and sophisticated hacking, tracking, and data mining technologies, dramatically increase the risk and the consequences of breaches of privacy and confidentiality. In turn, these elevated risks & consequences dramatically increase our obligations to ensure consumer choice; privacy & confidentiality; stateof-the science security; and rapid mitigation of unintended consequences. 23

24 Purpose of 42 CFR Part 2 The purpose of 42 CFR Part 2 and other regulations prohibiting disclosure of records relating to substance abuse treatment -- except with the patient s consent or a court order after good cause is shown -- is to encourage patients to seek substance abuse treatment without fear that by doing so their privacy will be compromised. Source: State of Florida Center for Drug-Free Living, Inc.,842 So.2d 177 (2003) at

25 42 CFR Part 2 Applies to Federally Assisted Services Applies to federally assisted individual or entity that holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment or treatment referral. Unit within a general medical facility that holds itself out as providing diagnosis, treatment or treatment referral. 25

26 Federal Privacy Regulations Patient consent must be obtained before sharing information from a substance abuse treatment facility that is subject to 42 CFR Part 2 or Title 38 (VA) Prohibition on re-disclosure without consent Not intended to prevent information sharing but to set standards on how to share patient information Source: 42 CFR Part 2 26

27 42 CFR Part 2 Limited exceptions for disclosure without consent : Medical emergencies Child abuse reporting Crimes on program premises or against program personnel Communications with a qualified service organization of information needed by the organization to provide services to the program Public Health research Court order Audits and evaluations Source: 42 CFR Part 2 27

28 42 CFR Part 2 Public Listening Session SAMHSA held a Public Listening Session on Wednesday, June 11, 2014 to solicit information concerning potential changes to the Confidentiality of Alcohol and Drug Abuse Patient Records Regulations, 42 CFR Part 2. Federal Register Notice of Meeting: Comments were due Wednesday, June 25, 2014 Comments are under review 28

29 42 CFR Part 2 Public Listening Session Topics Applicability of 42 CFR Part 2 Consent requirements Redisclosure Medical emergency provisions Quality Service Organization (QSO) provision Research Electronic prescribing and PDMPs 4/05/12/ /confidentiality-ofalcohol-and-drug-abuse-patient-records#h-8 29

30 Part 2 Listening Sessions Available on YOUTUBE 30

31 42 CFR Part 2 FAQs To help providers in the behavioral health field better understand privacy issues related to Health IT, SAMHSA, in collaboration with ONC has created two sets of Frequently Asked Questions (FAQs). These FAQs can be accessed at: and AQII_Revised.pdf Series of webinars by the Legal Action Center on 42 CFR Part

32 Mental Health Confidentiality Mental health records may be treated as ultrasensitive in many jurisdictions. Each state approaches the confidentiality of mental health records from their own perspective EHR systems have to recognize this variability in state statutes and regulations. State laws also often provide additional protections for HIV infection, genetics, minors, domestic violence, reproductive health etc. 32

33 Privacy & Best Care Possible: Ensuring Synergy Consumer-centric HIT Consent management: Consumer regulates access (privacy, confidentiality) Data segmentation & security Consumer HIT education & engagement HIT transparency, accountability, & consistency HIT consumer alert systems 33

34 Today s Behavioral HIT Topics Improving Practice Protecting Privacy SAMHSA s Solutions 34

35 SAMHSA s Behavioral HIT Portfolio Since FY2010, SAMHSA has awarded over $43 million in funds for HIT projects and programs. Approximately 54 grants have been awarded between FY2010 and FY2014. HIT projects in 28 states have been funded. 35

36 States with SAMHSA Funded HIT Grants States with SAMHSA HIT grants 36

37 SAMHSA s HIT Portfolio is Diverse SAMHSA s HIT portfolio bridges a range of strategies: e-therapy, telehealth, e-recovery, EHR systems, a Virtual Reality Clinic, Smartphone technology, webbase virtual recovery, telephone counseling, telepsychiatry, automated wellness calls, preadmission web-portals, and mobile strategies. Projects focused on underserved populations such as individuals living with HIV/AIDS in rural areas Projects focused on vulnerable, high-risk populations like veterans 37

38 SAMHSA s TCE-TAC Targeted Capacity Expansion (TCE) Technology Assisted Care (TCE-TAC) Grants enables SAT programs to: Expand care coordination through the use of HIT. Leverage technology to enhance or expand the capacity of substance abuse treatment providers to serve persons in treatment who are underserved. 38

39 Reducing the Human Toll: SAMHSA s OTP-CoC Initiative Enhancing Opioid Treatment Program Patient Continuity of Care through Data Interoperability. Purpose: to provide resources to opioid treatment programs (OTPs) that will enable them to develop EHR systems that fulfill regulatory requirements, achieve certified status, and become interoperable with other patient health record systems. 39

40 EHRs and PDMPs Electronic Health Record (EHR) and Prescription Drug Monitoring Program (PDMP) Data Integration Project Purpose: to link EHRs and pharmacy dispensing systems to PDMPs. 40

41 SAMHSA s Current HIT Projects Cooperative Agreements for Screening, Brief Intervention and Referral to Treatment (SBIRT) Up to 30% of funds can be used for HIT infrastructure development to support efficacy and sustainability of SBIRT program (EHR implementation, Telehealth, HIE integration, tablet based screening, web portals, etc.) Open Behavioral Health Information Technology Architecture (OBHITA) project Open Source, modular technology that can be integrated into existing EHR systems: Consent management and data segmentation, clinical decision support, patient assessments Development of behavioral health related data standards 41

42 SAMHSA Quality Measurement Activities Currently, SAMHSA is working with technical and clinical experts to develop additional quality measures to support integrated care for co-occurring disorders. E.g. diabetes and CVD screening in patients with SMI We are also working to promote the inclusion of additional behavioral health related quality measures in Meaningful Use Stage 3. Composite measure for substance use screening and follow up 42

43 Health Care Integration: SAMHSA s HIT Collaboration with HRSA 5 Sub-awards supported sharing of health records among behavioral health providers and general medical providers through state HIEs (ME, KY, IL, OK, RI) Develop infrastructure supporting the exchange of health information among behavioral health and physical health providers Led by the National Council 43

44 SAMHSA:HRSA HIE Grant Goals Identify barriers to inclusion of behavioral health in state HIEs. Identify technology and policy solutions for compliance with federal and state regulations. Develop a consent form template that is computable in a HIE Environment. Primary challenge around technical capacity for consent management. 44

45 Clinical Support Tools: SAMHSA s HIT Collaboration with ASAM The ASAM Patient Placement Criteria (PPC) is a multidimensional patient assessment tool linked to a comprehensive set of clinical decision support guidelines for patients with addiction disorders. Provides evidence based recommendations for level of treatment required SAMHSA worked with ASAM to develop a web service for the ASAM PPC which can be integrated with existing EHR systems. Pilot testing is ongoing Software will be free and publicly available 45

46 New Media & High Risk Populations: SAMHSA s Minority AIDS Initiative Minority AIDS Initiative (MAI) Program: Using New Media to Prevent Substance Abuse & HIV/AIDS for Populations at High Risk. Utilizing new media to promote targeted SA and HIV prevention messages to selected racial/ethnic populations at high risk for SA and HIV infection. 46

47 Mobile Technology: SAMHSA s Mental Health App Mental Health Recovery App o Developing technical specifications for a mobile app to support patients in recovery from mental disorders and co-morbid substance use disorders Developing mhealth policy o Endorsement/certification and maintenance of apps 47

48 Mobile Technology: SAMHSA-Supported A-CHESS App Addiction- Comprehensive Health Enhancement Support System (A-CHESS) Connection with a support team (other ACHESS users) Photo sharing, discussion group and healthy event planning Use of GPS to detect when user is near a high-risk location (for example, a liquor store) Video chat with counselor or discussion group 48

49 SAMHSA s Prevent High-risk Drinking among College Students Challenge: Prevent high-risk drinking among college students through cost-effective, portable, technology-based products. Products to effectively reach college students, parents, administrators, faculty, and staff. BeWise (Syracuse U.) Expectancy Challenge Alcohol Literacy Curriculum app (University of Central Florida) 49

50 SAMHSA s Primary Care Suicide Prevention App Challenge Assist in delivering evidence based practices to primary care providers whose patients present with suicidal ideation Develop mapp that provides care continuity and follow-up linkages for someone at risk for suicide who was discharged from an inpatient unit or emergency department. Relief Link, Emory University MyPsych ReachZ & Companion 50

51 Advanced Solutions for Privacy SAMHSA has been working with the ONC S&I Framework and the VA to develop open source technology for consent management and data segmentation to give the consumer granular control over information sharing. Support compliance with 42 CFR Part 2, Title 38, and state health privacy laws Open source tool that is being designed to integrate into existing EHR and HIE platforms +Privacy 51

52 Consent2Share Real world pilot tests: One state HIE, Prince Georges County Maryland, enabling exchange between a Part 2 program and a primary care organization 52

53 Solutions for Privacy Need to develop community consensus on how to define sensitive information (i.e. what information should be redacted if a patient doesn t want to share their substance abuse or HIV information) Need to communicate the benefits and risks to the patient very clearly SAMHSA is working with community experts to develop consensus in these areas through health level 7 (HL-7) 53

54 SAMHSA HIT Standards Development SAMHSA has been working with the International Standards Organization Health Level 7 (HL-7) to define consensus standards for behavioral health information to be included in the standard Continuity of Care Document (CCD) Based_Collaborative_Care We are also working with the ONC S&I workgroups for Long term coordination of care and Transitions of care to ensure that behavioral health information is included and aligned with the data standards in the BH-CCD %29+Initiative 54

55 Closing Thoughts: The Future of Behavioral HIT The HIT revolution is just beginning Technology is evolving rapidly Many of the tools that are being used now will be displaced by newer tools that support safer, higher quality, more efficient workflow Focus needs to be on long term potential for improving health care services and delivery through HIT and other innovative technologies 55

56 Lessons Learned Thus Far Transitioning to new technologies takes patience. In rural areas, the lack of technology infrastructure to provide requisite bandwidth for operation of telehealth equipment limits our ability to reach telehealth goals. Inflexible business relationships with vendors locks in programs to proprietary systems, which can prevent/impede adoption of more appropriate technology. Data plans and service. 56

57 Lessons Learned Thus Far (cont.) Provider reluctance to adapt to the use of innovative technologies. Staff reluctance to adapt to the use of new technologies. Limited patient access to the internet and to smartphones. Patient/client resistance. 57

58 Looking Forward: Behavioral Medicine & the Web Data Revolution Could Behavioral Medicine Lead the Web Data Revolution? Ayers et al. JAMA Billions of digital footprints from nearly all parts of the United States and from countries around the world provide a powerful opportunity to expand the evidence base across medicine. Behavioral medicine can be a leader in this web data revolution 58

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