Welcome to : Confidentiality, Substance Use Treatment, and Health Information Technology

2. TO HEAR this webinar, you must dial thenumber emailed to you in your registration confirmation and use the access code also provided in the same email. The audio pin is on the panel to the right of this screen. The webinar will begin at 3:00 p.m.EDT Thank you for your patience. Welcome to : Confidentiality, Substance Use Treatment, and Health Information Technology

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4. Four-Part Webinar Series on… Confidentiality, Substance Use Treatment, and Health Information Technology (HIT) First 3 Webinars Presented by the Legal Action Center 4th Webinar Presented by SAMHSA

5. Have a Question During this Presentation? Use the “Question(s)” feature on the upper right-hand corner of your screens to type in your question(s). We will answer questions at the end of the presentation.

6. Today’s Power Point presentations can be downloaded from http://www.lac.org/index.php/lac/webinar-archive Power Point presentations and materials from the Webinar series can be downloaded from http://www.lac.org and http://www.pfr.samhsa.gov The recording of this series will be available soon at the same locations.

7. SAMHSA’s Vision for Advancing Behavioral Healthcare throughHealth Information Technology Maureen Boyle, PhD Lead Public Health Advisor, Health Information Technology Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration May 25, 2012

8. President’s Vision for Health IT • Medical information will follow consumers so that they are at the center of their own care. • Consumers will be able to choose physicians and hospitals based on clinical performance results made available to them. • Clinicians will have a patient's complete medical history, computerized ordering systems, and electronic reminders.

9. “The increased use of health information technology is a key focus of our reform efforts because it will help to improve the safety and quality of health care generally while also cutting waste out of the system.” Kathleen Sebelius Secretary U.S. Department of Health & Human Services September 29, 2009

10. SAMHSA’s Strategic Initiative - Health IT • Goal: Widespread Implementation of HIT Systems that Support High Quality Integrated Behavioral Health Care for All Americans • Ensure the behavioral health provider networks fully participate in the adoption of Health IT • Working closely with the Office of the National Coordinator for Health IT to support inclusion of behavioral health

11. National HIT Landscape • The Health Information Technology for Economic and Clinical Health Act ( HITECH Act) • Meaningful Use, EHR Certification • Large national investment in HIT • Largely excludes behavioral health providers • The Affordable Care Act • Privacy and Confidentiality Regulations • HIPAA • 42 CFR Part 2 • State laws

12. Health Information Exchange Specialty Care EHR Primary Care Hospitals EHR EHR Clinics EHR Pharmacies EHR NwHIN HIE Labs EHR Health Plans Claims PHR Data Systems Patients Public Health Agency

13. HITECH Act • CMS and ONC define the requirements for meaningful use and certification of EHRs • Large national investment in HIT • Largely excludes behavioral health providers • Funding for Regional Extension Centers and Health Information Exchange Networks • NPRMs for Stage 2 were released on March 7th and the final rule is expected by the end of the summer • Multiple items of relevance to behavioral health • Clinical Quality Measures • Privacy and Confidentiality

14. Meaningful Use

15. Stage 2

16. Meaningful Use Incentive Program https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/eligibility_flow_chart.pdf

17. Useful Links • CMS: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/ • ONC: http://www.healthit.gov/providers-professionals/ehr-incentives-certification • Certified EHR: http://oncchpl.force.com/ehrcert/EHRProductSearch?setting=Inpatient • Regional Extension Centers http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__listing_of_regional_extension_centers/3519

18. The Affordable Care Act • Establishing patient-centered medical homes (PCMH) and accountable care organizations (ACO) • Focus on coordinating care and pay for performance • Formation of an ACO is contingent upon HIT for information exchange and quality measure reporting

19. Privacy and HIT • Privacy and Confidentiality Regulations • HIPAA • 42 CFR Part 2 • State specific laws

20. Ensuring Confidentiality and Trust • Increased accessibility to health records raises the question of how to ensure patient confidentiality and trust. • To be sustainable, electronic exchange efforts must establish trusting relationships with all participants, including patients. Melissa M. Goldstein, JD et al, 2010

21. 42 CFR Part 2 • Patient consent must be obtained before sharing information from a substance abuse treatment facility that is subject to 42 CFR Part 2 • The purpose of the statute and 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 181.

22. 42 CFR Part 2 • Patient consent must be obtained before sharing information from a substance abuse treatment facility that is subject to 42 CFR Part 2 • Prohibition on re-disclosure without consent • 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

23. MENTAL HEALTH CONFIDENTIALTY • Non-Substance Use Disorder mental health records may be treated as ultra-sensitive in many jurisdictions. • Each state approaches the confidentiality of mental health records from their own perspective • There are differences • There are similarities • EHR systems have to recognize this variability in state statutes and regulations.

24. Critical Health IT Questions • 42 CFR Part 2 and other regulations provide the ground rules. Careful analysis determines how the rules are applied to ensure effective treatment of substance use and mental health disorders. • Who needs what information when? • Who determines who needs what Information when? • How should psychotherapy notes be treated – as part of the patient record? • How should HIT systems be designed to control disclosure and re-disclosure of sensitive information

25. 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: http://www.samhsa.gov/healthprivacy/docs/EHR-FAQs.pdf and • http://www.samhsa.gov/about/laws/SAMHSA_42CFRPART2FAQII_Revised.pdf

26. The Health IT Challenge • Health IT will provide powerful tool to address the quality of care • The challenge is to be ready to use those tools • Only a small percentage of behavioral health providers have adopted interoperable Health IT systems • Even if the systems are in place, many do not have the personnel trained to effectively use them.

27. SAMHSA’s Strategic Initiative - Health IT • The SAMHSA is working to advance Behavioral Health through Health IT • Technologies/policies for privacy and confidentiality • Develop and test advanced functionality for Behavioral Health • Data segmentation and consent management • Behavioral Health Clinical decision support • Patient engagement and self-management • Development of data standards to ensure that information can be efficiently and effectively exchanged and interpreted • Behavioral health clinical quality measurement • Deliver technical assistance to increase adoption of HIT by the behavioral health community

28. Solutions for Privacy

29. Solutions for Privacy • Working to identify interim solutions for electronic exchange of health information that is subject to 42CFR Part 2 using existing technology platforms • Working with technology and legal experts • Working with the ONC Standards and Interoperability Framework and the VA to develop open source technology for consent management and data segmentation to give the patient dynamic control over what information is shared

30. Data Standards

31. Benefits of Data Standards • The integration of behavioral health and physical health is contingent upon health information exchange • It is critical that health care providers can interpret the information they receive from other providers • Standards for collection and storage of health information are needed for both interpretability and integration of data into the receiving record

32. Benefits of Data Standards • The adoption of interoperable data standards can improve patient care and facilitate research • More accurate and consistent data will be available • Quality measurement • Real time outcome tracking and surveillance • Standard information will allow programs to cross reference and validate patient information.

33. SAMHSA HIT Standards Development • Open Behavioral Health Information Technology Architecture (OBHITA) project: • 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) • Working with the ONC Standards and Interoperability Framework for Data Segmentation for Privacy (DS4P) to identify exchange standards for patient consent information across EHRs

34. Quality measurement

35. Quality Measurement • Quality measures have the potential to drive improvement in the healthcare system and can be used to demonstrate successful outcomes and reduced waste. • HIT performance and outcome measures will help answer the questions: • Are our goals measurable and evidence-based? • Are we reaching the right populations? • Are client and treatment properly aligned? • Are our programs successful?

36. Quality Measurement • Structural Measures • Healthcare facility's organization and resources, such as nursing staff levels, or the presence of a behavioral health provider on a care team • Process Measures • The actual techniques used to treat patients, such as screening and brief intervention for alcohol use or depression • Outcome Measures • The consequences of a patient's interaction with the healthcare system (i.e. Did the patient’s depression score decrease with treatment)

37. SAMHSA Quality Measurement Activities • Developing clinical quality measures for behavioral health that are relevant for the meaningful use program

38. SAMHSA Quality Measurement Activities • Two contracts are working with technical and clinical experts to determine what additional quality measures need to be developed to support behavioral health care • Both in primary and specialty care • New quality measures will be developed to fill gaps that are identified through this process

39. ADVANCED TOOLS

40. BH Treatment Lifecycle Brief Intervention or Referral Brief Patient Assessment Full Patient Assessment Patient Identification Clinical Decision Support Patient Education and Engagement Patient Placement Shared Decision Making Quality Data Reporting Patient Treatment Outcome Tracking

41. BH Treatment Lifecycle Brief Intervention or Referral Brief Patient Assessment Full Patient Assessment Patient Identification Clinical Decision Support Patient Education and Engagement • EHRs or PHRs can be used to: • Collect patient reported information • Alert healthcare providers of patients at risk • Educate patient and link them to resources • Positive reinforcement Patient Placement Shared Decision Making Quality Data Reporting Patient Treatment Outcome Tracking

42. BH Treatment Lifecycle Brief Intervention or Referral Brief Patient Assessment Full Patient Assessment Patient Identification Clinical Decision Support Patient Education and Engagement • EHRs/PHRs can collect patient reported standard assessments • Computer adaptive testing to minimize burden • Automated Scoring to determine the level of risk • Alerts and reminders • To rule out alternative diagnoses • To assess contributing physical health problems • To alert provider to critical risks (i.e. suicidality) • Collect standard data on patient symptoms Patient Placement Shared Decision Making Quality Data Reporting Patient Treatment Outcome Tracking

43. BH Treatment Lifecycle Brief Intervention or Referral Brief Patient Assessment Full Patient Assessment Patient Identification Clinical Decision Support Patient Education and Engagement • Checklists for evidence based care • Links to clinical guidelines and information • Sharing information with patients • Linking patients to community resources • Consent Management for health information exchange • Health Information Exchange tools • Referral appointment scheduling • Referral management and follow up tools • Care coordination tools Patient Placement Shared Decision Making Quality Data Reporting Patient Treatment Outcome Tracking

44. BH Treatment Lifecycle Brief Intervention or Referral Brief Patient Assessment Full Patient Assessment Patient Identification Clinical Decision Support Patient Education and Engagement • Decision support for level of care • Treatment plan is auto-populated and modified by clinician • Methods for capturing standardized data on non-pharmacologic treatments will be needed Patient Placement Shared Decision Making Quality Data Reporting Patient Treatment Outcome Tracking

45. BH Treatment Lifecycle Brief Intervention or Referral Brief Patient Assessment Full Patient Assessment • Evidence based practice checklists • Links to clinical guidelines • Alerts to identify patients who are ‘falling through the cracks’ • If critical prescriptions are not refilled • If appointments are missed • Patient progress monitoring • Clinical decision support for adjusting treatment: • Step up to the next level of care • Continue in current care level • Enroll in recovery maintenance services • Data standardization to ensure interpretability across providers • Care coordination and management tools Patient Identification Clinical Decision Support Patient Education and Engagement Patient Placement Shared Decision Making Quality Data Reporting Patient Treatment Outcome Tracking

46. BH Treatment Lifecycle Brief Intervention or Referral Brief Patient Assessment Full Patient Assessment Patient Identification Clinical Decision Support • Structure, Process and Outcome measurement • Individual and community based results • Determine if evidence based protocols were used • Assess the efficacy of individual providers and healthcare systems • Public health reporting • Research to improve health service delivery Patient Education and Engagement Patient Placement Shared Decision Making Quality Data Reporting Patient Treatment Outcome Tracking

47. Learning Systems • Data can be analyzed to correlate symptom profiles and treatments used with Outcomes: • Algorithm that determine the treatment plan can be updated based on feedback loop • Creates continuous learning environment • Personalized medicine • Support research into the biological basis of behavioral health disorders

48. Patient Engagement • Capturing patient reported data in the EHR • Interface with the patient through a web portal or PHR • Provide the patient with health information tailored to their own risks and to level of health literacy • Provide community and online resources • Tools to support shared decision making • Goal setting and tracking • Link with mHealth tools

49. SAMHSA HIT Activities: Patient Engagement • Mobile Health Tools • Telephone Monitoring and Adaptive Counseling program, part of Access to Recovery: • Life: Wire – A text messaging platform that supports ongoing client contact & a continuously updating database that can be used to evaluate service effectiveness & make program changes to support improved outcomes. • Addiction Comprehensive Health Enhancement Support System (A-Chess) – • Features online peer support groups and clinical counselors, a GPS feature that sends an alert when the user is near an area of previous drug or alcohol activity, real-time video counseling, and a “panic button” that allows the user to place an immediate call for help with cravings or triggers.

50. SAMHSA HIT GRants