FAQs for CHF RASAI participants using a certified EHR (12/5/2014) Q1. Answer: Q1 Answer Reason Q2. Q2 Answer: Q2 Answer Reason

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1 FAQs for CHF RASAI participants using a certified EHR (12/5/2014) The certified EHR mirrors and supports clinical workflows by operationalizing national health information data and technology standards. These standards are central to implementing clinical best practices, especially those expressed in the Meaningful Use criteria for patient care. The RASAI data collection instrument was designed in consultation with many and varied stakeholders and with paper-based systems in mind. Developed with great thoughtfulness, it seeks to capture patient level data for assessing and evaluating the implementation of SBIRT for adolescents. The RASAI data standards and the EHR national data standards align, but not perfectly. Participants using certified EHRs, who must follow the national standards, are requesting technical assistance to address this. The National Council staff prepared this set of FAQs, a compilation of answers to individual questions posed by participants using an EHR. The FAQs are predicated on the understanding that the RASAI data collection instrument is intended for those using paper-based systems, but should be referenced by EHR users to gain understanding of the required data collection topic areas (see FAQ #8). Q1. Transgender is not in the set of responses (includes only Male and Female ) AND/OR we collect data on gender in a separate question. How should we answer this question? Q1 Answer: Select either Male or Female. Report as Sex. If you collect Gender information in a separate field, do not include it in the report. Q1 Answer Reason The answer provides the data required by the stakeholders, without compromising data integrity or adding to the participants data collection burden. The question Sex and the response set Male and Female is a biologic indicator and the data standard since Recently (2010) OMB noted that Sex and Gender are two separate categories with two separate meanings. They established workgroups to develop the data collection and reporting standard for Gender. Sexual Orientation is considered a 3 rd category and also has workgroups. The OMB is likely to circulate the data collection and reporting standard for Gender in 2015 The OMB data standard is reflected in the EHR. The field collects the two biologic indicators, only. - Most systems do not collect Gender per se, but the field that should be labeled Sex may be labeled Gender in the user interface. The current standard is to label this field Sex. If you current system collects information on Gender as a separate category, and you would like to report it, this is not feasible. The Excel spreadsheet does not include this as a separate question/answer, so there is no space for a response. Q2. The Smoking field does not include Smoker, Current Status Unknown and Unknown If Ever Smoked. I think these are required for Meaningful Use. If these are selected could we have them default to one of the selections on the form? If so, we will need to know which ones to default them to? Q2 Answer: Respond according to how your EHR is set up to respond, including the selections that are not in the paper-based form. Q2 Answer Reason The answer minimizes burden to data collection and reporting. It provides the data that the stakeholder requested, in a standard format. There are eight categories of response in the data standard: (1) Current every day smoker.

2 (2) Current some day smoker. (3) Former smoker. (4) Never smoker. (5) Smoker, current status unknown. (6) Unknown if ever smoked. (7) Heavy tobacco smoker. (8) Light tobacco smoker. - The RASAI paper-based data collection instrument collects answers about half. The other half was dropped to accommodate the provider working in the paper-based environment. - This accommodation for the paper-based system does not add to the burden for EHR user. Responses are mutually exclusive, so only one can be reported this can be any one of the eight options in the response data set. Q3. Do you only want Axis I Diagnoses (or diagnostic codes included)? We are still using DSM-IV-TR for our diagnoses. Q3 Answer: Include the diagnoses however they appear in the Problem List generated by your EHR. Q3 Answer Reason: The answer provides the data required by the stakeholders, without compromising data integrity or adding to the participants data collection burden. - Health reform and EHRs support the coordination of patient care by using a standard data set (the Common Meaningful Use Data Set). In this data set, all patient Problems appear in one data string. These data are included in the referral process as a Meaningful Use requirement. - Cleaning the data by removing Problems that may not be related to MH/SA introduces extra steps outside of the EHR, and negatively affects data validity and reliability. In re: ICD-9 and DSM-IV TR: The questioner should understand that DSM IV codes are not actually used in the EHR. Only ICD codes are used. o o ICD codes are the national standard, and they are free. DSM codes are not a national data standard, and using them in an EHR requires payment of licensing fees. Using the free ICD-9 codes in the EHR and calling them DSM-IV-TR codes is a long-standing BH EHR vendor practice. It works for now because the American Psychiatric Association (APA) adopted the ICD-9 coding scheme for mental health diagnoses and applied them to the DSM-IV. There is an almost 1:1 match between the DSM-IV diagnostic code and description, and the ICD-9 medical code and description. The DSM descriptions sometimes include more detail that the ICD does not use. Although most clinicians believe that they are using a cross-walk of DSM-IV to ICD-9, this is not the case. Since the code numbers are identical and the diagnoses match, there is nothing to crosswalk! This 1:1 scheme was not continued with ICD-10 and DSM 5. A DSM 5 code cross-walk to ICD-10 codes will be necessary in order to use the DSM 5 codes in the EHR. The crosswalk is available and providers who decide to use it will be required to pay the licensing fees. Q4. For the field Score warrants BI or RT, but BI or RT were not pursued what would cause a Yes response? Is this for when clients refuse the recommended interventions or if the clinician makes a different recommendation, or both? Q4 Answer: Treat Screening, BI and RT as three separate processes along a continuum called SBIRT Clinical Decision Support Workflow (see below). Track responses to each decision point in this process. Report an answer of Yes or No for BI and RT decision points. Example below uses CRAFFT:

3 Q4 Answer Reason The answer resolves the confusion unintentionally introduced by the question design. It provides the stakeholder with the data requested and offers the participant clear decision points, where data collection and reporting are feasible. It protects the quality of the data by leveraging EHR functionality. It supports implementation of the Referral Loop. - As the original question indicates, the context for the question, or use case scenario, is not clear. This means that the appropriate response can t be identified. - In addition, either Yes or No may indicate agreement with the statement ( No, [it] was not pursued or Yes, [it] was not pursued. ) - The question asks for one answer, but refers to two decision points one for BI and one for RT. There is no way to indicate which of these the answer refers to. Q5. What are the definition differences between No and Refused for Patient attended treatment? Q5 Answer: Use either Yes (for patient attended ) or No (for patient did not attend) initial referral appointment. Please note that the Drug and Alcohol score (recently added to the RASAI data collection set) will not be used to prompt any intervention or referrals and will only be used for outcomes data for the study. Q5 Answer Reason The answer resolves the confusion unintentionally introduced by the question design. It provides the stakeholder with clear decision points, where data collection and reporting is feasible. It protects the quality of the data by leveraging EHR functionality. It supports implementation of the Referral Loop. - To be reliable and valid, the responses must be mutually exclusive, such as Yes No, or Red Green Blue. - Refused is in the subset of qualifiers for No. It is one of the many forms that No can take. So it is not a mutually exclusive selection. - The clinician has to decide between No and Refused. Since No includes Refused, it does a better job of responding to the question. The answer also supports clinical best practices. The EHR is configured to implement this process as Clinical Decision Support as diagrammed. Meaningful Use also requires closing the Referral Loop completely. The question references the lowest level of referral follow-up (did they attend). The Meaningful Use standard for Transitions of Care easily supports answering that question.

4 The following general guidance applies to both Questions 6 and 7: 1. The OMB data standard (Oct 1997) collects Ethnicity and Race separately. 2. This guidance notes that this reflects the clinical best practices standard. 3. Understand that the selections represent categories: a. The Ethnicity category includes many distinct ethnicities that are categorized as either Hispanic or Latino or Not Hispanic or Latino. b. Each category for Race includes dozens of races organized within that category. c. When Ethnicity is identified, the response to Race can then be organized according to ethnicity. So, a patient may be Hispanic or Latino and also American Indian or Alaska Native. They may be Not Hispanic or Latino and also American Indian or Alaska Native. 4. The field must allow the clinician to indicate multiple Races when this is the case. For example, ethnicity may be Not Hispanic or Latino and Race may be both Asian and White. 5. Note that selecting Mixed or Other immediately eliminates the patient from consideration in addressing many health issues within a population-based clinical management approach (required by Meaningful Use), including addressing health disparities. 6. It also does not support a clinical approach that is culturally competent. Q6. We do not collect Ethnicity (Hispanic/Latino) as a separate question. It is combined with Race. How should we report this? Q6 Answer: For now, respond as your system is set up to respond. If the data is collected with Race, then include it there. However, understand this is a clinical best practices concern first, and a data collection concern second. Talk with your clinical and IT leadership about adopting the national standard as soon as possible. Q6 Answer Reason The answer supports the collection of data that meets the needs of the stakeholders, while encouraging best clinical practices in implementing SBIRT. - As noted in the general guidance above, separating Ethnicity and Race is an OMB standard that dates back to October, It was immediately adopted by all federal agencies, including the National Institute of Standards and Technology (NIST). Software developers usually pay close attention to NIST standards, so even the most outdated systems should have implemented this change by now. - The standard for the response is Hispanic or Latino or Not Hispanic or Latino. - In this instance, the investment of resources to modify the EHR and train clinical staff is strongly recommended as essential to clinical best practices. - Here is some guidance for the IT staff - Legacy data can be preserved by parsing Ethnicity data from the Race/Ethnicity column in the database and moving it into a separate Ethnicity column. The field in the user interface should be labeled Ethnicity and point to the data in that column. The clinician can update the fields in the active records. Q7. The possible answers to the question concerning Race do not include Mixed Race. How should we respond when more than one category can apply? Q7 Answer: For now, respond as your system is set up to respond. If the data is collected with this option or the option Other, then report it as the answer. However, understand this is an important clinical best practices concern, not just a matter of following a data standard. Talk with your clinical and IT leadership about adopting the national standard as soon as possible. Q7 Answer Reasons - As noted, the OMB standard for identifying Race dates back to October, It was immediately adopted by all federal agencies, including the National Institute of Standards and Technology (NIST), so

5 should have been incorporated into even the most outdated systems by now. - The standard for the response is American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander and White. - Since each category includes many races, when the patient identifies two or more races, the clinician should verify that these are not already included in the first category the patient selects. - When the patient does identify two or more races in more than one category, understand that the answer is supposed to allow multiple entries the five categories noted above are not mutually exclusive. - Understand that selecting Mixed or Other immediately eliminates the patient from consideration in addressing many important health care issues associated with ethnic and racial groups, including population-based treatment planning, culturally competent care and addressing health disparities. - Here is some guidance for the IT staff After Ethnicity data has been parsed from the Race/Ethnicity column in the database and moved into a separate Ethnicity column you can address concerns re: Race. Only the five categories in the standard should be included, usually as a list with checkboxes, allowing the clinician to select as many as apply. Over time, the clinician can update active patient records in their caseloads. Q8. Does the RASAI data collection instrument itself have to be turned in? Q8 Answer: No. The RASAI data collection instrument is intended for those using paper-based systems. It should be referenced by EHR users to gain understanding of the data collection topic areas. Q8 Answer Reasons The answer supports the stakeholder interests re: the quality and validity of patient health information data. It allows for the provision of as complete a data set as is possible, without increasing the data collection and reporting burden on the participant or negatively impacting data integrity. It supports the implementation of best clinical practices re: SBIRT for Adolescents, using the EHR. - As noted in the introduction, the RASAI data collection instrument standards and the EHR data standards align, but not perfectly. - Those using EHRs can follow the national data and technology standards built into the EHR for demographic data collection and Clinical Decision Support. - It avoids introducing additional steps outside the EHR (that will have to be recorded in the EHR at some later date), or negatively affect data integrity. - It avoids diverting IT resources towards modifying a legacy system unless it is clinically indicated). - It supports financial sustainability - since SBIRT is an approved prevention service, the referral process helps EPs meet the standards for Meaningful Use. - It supports closing the Referral Loop. For all technical assistance on data collection and reporting, and assistance with the paper-based tool: Aaron Surma Quality Assurance Associate SAMHSA/HRSA Center for Integrated Health Solutions National Council for Behavioral Health (c) integration.samhsa.gov For technical assistance on using the EHR: Colleen O'Donnell, MSW, PMP, CHTS-IM Policy and Practice Improvement Specialist The National Council for Behavioral Health 1701 K St, NW Ste# 400 Washington, D.C W: x278 C:

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