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1© 2015. All Rights Reserved.
www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: [email protected]
The 2015 OPEN MINDS Technology & Informatics InstituteOctober 27, 2015 | 2:00pm – 3:15pm
George Braunstein, Senior Associate, OPEN MINDS
How Can We Improve Behavioral Health Data Exchange? The Challenges & Opportunities Of HIE
2© 2015. All Rights Reserved.
1. The Challenges & Opportunities Of HIE
2. HIE In Action: State and Provider-Level Case Studies• Jody Denson, M.P.A., Project Manager, Kansas Health Information Network
• Bill Cadieux, Chief Information Officer, The Providence Center
• Pamela Vaught, Ed.D., President & CEO, Comprehend, Inc.
3. Questions & Discussion
Agenda
The Challenges & Opportunities Of HIE
4© 2015. All Rights Reserved.
Why Is Sharing Health Information Important?
29% of people receiving medical services also have a behavioral health disorder
68% of people being treated for a mental illness also have a medical diagnosis needing treatment
Emergency room visits for people with a behavioral health diagnosis are 3.5 times higher than the general population
5© 2015. All Rights Reserved.
Goals of Health Information Exchange (HIE)
Reduce health care costs by improving efficiencies and streamlining care– Avoid readmissions
– Avoid medication errors
– Improve diagnoses
– Decrease duplicate testing
Increase communication and coordination across providers
Promotes patient-centered, whole-person care
6© 2015. All Rights Reserved.
Three Key Forms Of HIEDirected Exchange
• Ability to send and receive secure information electronically between providers
• Example: A primary care physician (PCP) shares information about a consumer with a specialist. The specialist shares their diagnosis and findings with the PCP
Query-based Exchange
• Ability to find and/or request information on a consumer from other providers
• Example: A consumer goes to the Emergency Room, where the ER physician queries the consumer’s medical history to help formulate a diagnosis
Consumer Mediated Exchange
• Ability for consumers to gather and control the use of their health information across different providers
• Example: The consumer is in control of their own information and can share it as needed with physicians and specialists. Additionally, the consumer can track their own care and make updates to information as needed.
7© 2015. All Rights Reserved.
Are Organizations Sharing Data?
As of August of 2013, the federal Agency for Healthcare Research and Quality (AHRQ) estimated:– There were over 280 HIEs across the U.S.– More than 50% of the hospitals in the U.S. were participating in HIE-enabled
organizations
As of 2013, the Office of the National Coordinator for Health Information Technology (ONC) estimated:– 39% of physicians exchanged information with other providers – 14% of physicians exchanged information with providers outside of their
organizations
Black Book Market Research LLC estimates that in the first quarter of 2015, 94% of providers, healthcare agencies,
patients and payers are not able to meaningfully share data
8© 2015. All Rights Reserved.
Federal Regulation & Promotion Of HIE
Meaningful Use – Getting data into an electronic format was the first step– Stage 1, 2011-2012 - Data capture and sharing
– Stage 2, 2014 - Advance clinical processes
– Stage 3, 2016 - Improved outcomes
The HITECH Act – Moves to the next level to increase efficiency through the use of EHR systems and information exchange – Nationwide Health Information Network Exchange - Group of federal agencies and
private organizations that securely exchange electronic health information, and are helping to develop Nationwide Health Information Network standards, services, and policies.
– Direct Project - Launched in March 2010, developing standards and services to enable secure, directed health information exchange at a more local and less complex level among providers
9© 2015. All Rights Reserved.
State Regulation & Promotion Of HIE
Federal Grants to Promote State Exchanges
March 2010 – Office of National Coordinator (ONC) awarded State Health Information (State HIE) Exchange Cooperative Agreement Program grants to 56 states, eligible territories, and qualified State Designated Entities (SDE)
January 2011 – ONC awarded an $16 million in HIE Challenge Grant Program awards to 10 awardees
Examples of State Information Exchanges Colorado (regional) – Colorado Regional Health Information
Organization (CORHIO)
Illinois: ILHIE
Kentucky: KHIE
Maine: HealthInfoNet
Michigan – MIHIN
Nebraska (regional) - eBHIN
Oklahoma: OHIET
Rhode Island: Current Care
Rochester, New York (Behavioral Health, Regional) -RECOVERYNET
Rochester, New York (Regional) - RochesterRHIO
Texas (statewide behavioral health) - CMBHS
10© 2015. All Rights Reserved.
Barriers To Behavioral Health Information Exchange State and federal limitations on sharing behavioral health information
– Genetic information
– Psychotherapy notes
– Substance abuse treatment - federal code 42 CFR part 2
– More restrictive state standards
Technical barriers - standards for data segmentation not yet fully developed
Business barriers– The exclusion of behavioral health as part of meaningful use incentives
– The inability to process granular consent data requests
– Developing and setting up data exchanges is costly
Consumer trust– Concern about sharing personal information
– Stigma of a mental health/addiction diagnosis following a consumer through all health care interactions
HIE In Action: State and Provider-Level Case Studies
Jody Denson, M.P.A. Project ManagerKansas Health Information Network
How Can We Improve Behavioral Health Data Exchange? The Challenges & The
Opportunities Of HIE
Kansas Health Information Network, Inc.
Agenda
• KHIN Background
• State Legislation & Patient Consent
• 42 CFR Part 2
• Mental Health Center and Integrating with HIOs
• Questions
KHIN
Kansas HIE Landscape
KDHE effective July 1, 2013
KHIN Membership Growth
KHIN Production Growth
KHIN Key Statistics
• Over 2 Million + Unique Patients in KHIN Exchange
• Over 5 million available for query
• 1,230+ KHIN Members
• 600 +Health Care Organizations in Production
KHIN HIE Products 2015• Secure Clinical
Messaging/DIRECT
• Query Based Exchange• Full HIE–Query
functionality• Web based access
• Image Exchange• Personal Health Record
• State level interfaces• Immunizations• Syndromic Surveillance• Reportable Diseases• Cancer Registry• Infectious Disease
Registry• Alerts and Data Extracts
Data and Analytics
Available Reports Include:• Demographics• New Patient Information• Physician Volume• PQRS Measures• ED High Utilizers• Chronic Care Conditions• Insurance Utilization
Kansas Key HIE Achievements• 2011 Passage of KHITE Legislation normalizing all patient
consent requirements with HIPAAz2012 Legislature reconfirmed KHITE
• KDHE authorized to provide oversight
• KDHE technology functionality requirement for security override
• Patient consent• Life threatening emergency
• 2013 KHIN Policy and Procedure
KHIN Security Override Policies
• Kansas is an opt-out State• Obtaining health information from other
Participants for care and treatment of patients that (1) have opted-out of including their health information in KHIN, and/or (2) have records and information accessible through KHIN that are protected under 42 C.F.R. Part 2
• KHIN does not disclose “opt-out” patient’s health information and/or a health information protected under Part 2, unless (1) a medical emergency exits, or (2) Patient consent is obtained pursuant to a Part 2-compliant consent form at the point-of-care.
42 CFR Part 2
Providers and Medical Facilities that are BOTH:
• “federally assisted” and meet the definition of a program under 42 CFR Part 2.11
-and-
• “hold themselves out as providing and provides alcohol or drug abuse diagnosis, treatment or referral for treatment” (42 CFR Part 2.11)
Blocking Substance Abuse Patient Data – Who Must Comply
42 CFR Part 2
• authorized, licensed, certified, or registered by the federal government
• receives federal funds of any kind • assisted by IRS through a grant of tax exempt status
or allowance of tax deductions for contributions• authorized to conduct business by the federal
government (e.g., Medicare provider, conduct methadone maintenance treatment, or registered with the Drug Enforcement Agency to dispense a controlled substance used in the treatment of substance abuse)
• is conducted directly by the federal government.
What does “Federally Assisted” Mean?
42 CFR Part 2 Patient Consent Considerations for Data Sharing
Two Options1. Block Data at the EHR level.
•Concerns:• Data is NOT available in an
emergency• Data is NOT available when a patient
gives consent
2. Block Data at the HIE level.•Concerns:
• On going communication between provider and HIE
• Notification of security override without patient consent
Identifying Substance Abuse Patients to be Blocked
Who is Blocked:• Primary diagnosis
Secondary diagnosis• Patients enrolled in substance abuse
programs
When are they blocked:• At intake• At billing
Mental Health CentersWho is Using HIE?
• 15 Mental Health Centers are KHIN members and have QSOAs
• Health Care Home Staff
• Hospital Diversion Staff
• Management
• Medical Records
• Emergency Services
Mental Health CentersWhy Are They Using HIE?
• Patient seen recently at hospital and why• Alerts• Lab values• Medications• Emergency situations• Find diagnosis to qualify for certain programs• Find diagnosis to update diagnoses for ICD10/DSM5
(for clients that don’t see a doctor at the MHC)• Patient referrals• Verify patient home addresses and insurance
What are the Drivers for HIEs Beyond 2015?
Care Coordination is critical across providers.• Shared Risk encourages use of HIE• HIE Alerts for High Risk Patients• Emergence of Care Coordination software/modules
that are fed by the HIE.• New payment codes for care coordination
What are the Drivers for HIEs Beyond 2015?
The silos between behavioral and physical health care are coming down.
• Single location for all patient data (including Part 2-substance abuse data).
• Reduction of stigma associated with mental health
Bill CadieuxChief Information Officer The Providence Center
Our Road to a Successful Health Information Exchange
Bill Cadieux, 10/20/[email protected]
www.provctr.org
Services of The Providence Center
34
Who we Serve
35
Our HIE Partner
Rhode Island Quality Institute (www.riqi.org)
RIQI is a non-profit and a collaboration of leaders in the Rhode Island
community including CEOs of hospitals, health insurers, and businesses,
along with leaders of consumer groups, academia, and government.
A group determined to significantly improve the healthcare system in the
state by building on the availability and advantages of health information
technology.
36
CurrentCare, Rhode Island’s HIE
37
CurrentCare
An opt in health information exchange repository
Nearly 1 in 2 Rhode Islanders enrolled
90% of RI prescription data from retail pharmacies
90% of RI laboratory data
All Rhode Island acute care hospitals (with the exception of the VA) submitting data on admission, discharge, and transfers
205 distinct data sources
38
Three Enrollment Options
39
One Other Important Choice
As a client should I send my TPC behavioral data to CurrentCare for other providers to view?As a substance use provider we are governed by Federal Regulation 42 CFR Part 2For The Providence Center to upload client data into CurrentCare our clients must agree by signing a release of information.
The release is only valid for one year.
An automated email system will notify a provider on the morning the client is scheduled to be seen if the release is about to expire within 60 days.
40
RIQI and The Providence Center
Started the interface project with RIQI in September of 2012.
RIQI MOU and vendor contract by the end of November 2012.
While a MOU is important strong relationships and constant communication is key to success.
Twice weekly conference calls between TPC, RIQI and the vendor.
41
How we felt about the project
42
Barriers to Success
Technical – will it all work?
Cultural – will everyone want to share?
Workflow – what haven’t we thought of?
Privacy – how does legal feel about all this?
43
Technical
ONC and NwHIN “Direct” messaging protocols Encrypted, authenticated e-mail service provided by Health
Information Service Vendors. Primary electronic transport mechanism to Currentcare. Initial connectivity and reliability problems were unexpected.
Best approach - Put techs together from different vendors one-on-one in real-time to solve problems.
44
Cultural
Pushback from clinical staff on sharing behavioral health and addictions data.
Counter to clinical training and the ever present threat of HIPAA penalties.
For the most part clients felt the benefit outweighed the risk.
45
Workflow
Three primary concerns around sustainability Paper-based enrollment form would be very unpopular with our staff
that have been paperless since 2007. Accessing Currentcare without knowing if a client was enrolled could
be frustrating to some, especially in the early stages. Because the release to upload substance use data into CurrentCare
is only valid for one year tracking and notification to renew would be critical.
SolutionDevelop a auto-populating enrollment form. Flag clients that are enrolled in the EMR.Develop a release of information and notification system.
46
Confidentiality
Federal regulation 42 CFR Part 2Requires much tighter control (than HIPAA Privacy and Security) of
substance abuse information.
Two approaches Segmentation – Technology-based separation of substance use data.
ONC’s DS4P initiative has had initial success. The Rhode Island approach. Use a release of information and only
send data to the HIE if a current release is in place.
47
Go Live
On March 8th, 2013 we submitted our first live record to the production gateway with Inpriva NwHIN Direct account.
On March 21st,2013 we began fully automated production uploads to CurrentCare.
Our Continuum of Care data includes…DemographicsDiagnoses Admissions/discharges to careMedications Allergies
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What are our NumbersEnrollmentOpt in, can opt out at any time Allows (all/named/emergency) providers to view the record Three forms (Enroll now, I have enrolled elsewhere, I decline to enroll)
Release Opt in, can opt out at any time, expires in one yearRequired for TPC (a 42 CFR Part 2 provider) to submit “ANY” client data to
CurrentCare Two Forms (I agree, I decline)
Of approximately 7,500 active clients (42% enrolled) Enrolled at TPC – 2,014 Enrolled elsewhere – 1,099 Signed release to upload their data – 2,215 (unduplicated)Declined enrollment – 54Declined release – 30
49
CurrentCare Enrollments by Age
50
0
100
200
300
400
500
600
700
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85
Count of Enrollments Number of Clients in Age Group
Who is Enrolling by Race and Ethnicity
White44%
Black/African American
11%
Asian20%
Unknown13%
Active Clients by Race
Latino/Hispanic29%
Non Latino/Hispanic71%
Active Clients by Ethnicity
Latino/Hispanic13.68%
Non Latino/Hispanic67.67%
Enrolled by Ethnicity
White65.6%
Black/African American
22.0%
Asian3.0%
Unknown7.9%
Enrolled by Race
51
The Future
52
Pamela Vaught, Ed.D. President & CEO Comprehend, Inc.
Comprehend, Inc. is a private non-profit corporation which is a licensed community mental health center in Kentucky We provide planning, prevention, treatment, support and advocacy in the areas of behavioral health, substance use disorders, and intellectual/developmental disabilities Comprehend, Inc. has a $12.5 million dollar annual budget and a staff of approximately 170 employees Comprehend, Inc. is governed by an 18 member board serving 5 northeastern Kentucky counties
A secure, interoperable network that meets national standards
Participating providers with certified electronic health record technology (CEHRT) can access, locate and share needed patient health information with other providers at the point of care.
The first pilot hospital was connected to KHIE in April 2010, while statewide rollout began in January 2011. The pilot participants included six hospitals and one clinic.
As of September 1, 2015, KHIE has 762 signed participation agreements, which represents 3,077 locations
KHIE has a total of 1,087 provider locations submitting live data and actively exchanging information.
Additionally, 90% of acute care hospitals are live on KHIE.
Behavioral health has not gone live to date in the exchange
What is the best solution to serving the medical needs of patients?
The solution lies in integrated care – the coordination of mental health, substance abuse, primary care, and oral health services
Integrated care produces the best outcomes and is the most effective approach to caring for people with complex healthcare needs
Health Information Technology is an important part of providing integrated treatment by linking 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
•Increase the quality of care•Increase access to services and support
•More stringent privacy and HIPAA requirements
•Subjective diagnoses
•Majority Non-pharmacological treatments
•Less emphasis on labs & imaging
•Need for strong and continued patient engagement
•Role of the family and social support structure
Increased accessibility to health records raises the question of how to ensure patient confidentiality and trust.
Information sharing at this level is dichotomous to clinical training for professionals. The concepts of confidentiality must be reframed
Perceived or real beliefs from both patients and professionals that information can influence medical decisions in an unhealthy and negative manner
How much is too much to share?
Technological limitations especially in rural areas
42 CFR Part 2 and other regulations provide the ground rules, but how those rules are applied to ensure effective treatment of substance use and mental health disorders needs to be determined through careful analysis. Who needs what information when? Who determines who needs what Information when? How should psychotherapy notes be treated – as part of the patient record?
“In order to achieve any level of systemic durability and success, electronic exchange efforts must establish trusting relationships with all participants, including patients”. (Melissa M. Goldstein, JD et al, 2010)
o Why ?o What if I don’t want any other doctor to know about my mental
illness?o What if I don’t want all my information shared?o I don’t know anything about computers-How I am going to find out
my information?o Will I be treated differently if they know I have a mental illness?o My other doctors don’t understand mental illnesso How will my medical information be used? Can they use it against
me?
Improved technological system especially in rural areas Expected outcomes of the integration of health IT with
existing EMR include:•Improved access to primary care services and
shared medical status•Increased prevention capabilities•Increased ability to identify when intervention is
needed to avoid serious health issues•Enhanced capacity to holistically serve those with
mental health & substance abuse disorders through screening and services.
Even in today’s technologically advanced world, many people don’t have computers, internet nor know how to use or access them
Behavioral healthcare information remains very private and stigma ridden to many patients
There is a true lack of understanding by patients and some providers of the physical health-behavioral health connection
In spite of medical advances, there are still medical providers who have no desire to work with patients with mental illness and who invalidate mentally ill patients due to their diagnosis
STEPS TAKEN• Inclusion in the KHIE at
state level
• Contracted with EMR vendor for inclusion in health information exchange
• Consumer Portal
• Education of staff regarding value of health information exchange and role of confidentiality
NEXT STEPS
Waiting on State and EMR vendor to include behavioral health
Continue education of patients around value of health information exchange
Continue improving our technology to allow for health information exchange
Questions & Discussion
www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: [email protected]
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