SAMHSA Health Information Technology Initiative

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

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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

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• Todays Power Point presentations can be
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• Power Point presentations and materials from the
  Webinar series can be downloaded from
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  The recording of this series will be available
  soon at the same locations.

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SAMHSAs 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

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Presidents 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.

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• 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
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SAMHSAs 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

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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

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Health Information Exchange
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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

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Meaningful Use
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Stage 2
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Meaningful Use Incentive Program
https//www.cms.gov/Regulations-and-Guidance/Legis
lation/EHRIncentivePrograms/downloads/eligibility_
flow_chart.pdf
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Useful Links

• CMS https//www.cms.gov/Regulations-and-Guidance/
  Legislation/EHRIncentivePrograms/index.html?redire
  ct/EHRIncentivePrograms/
• ONC http//www.healthit.gov/providers-professiona
  ls/ehr-incentives-certification
• Certified EHR http//oncchpl.force.com/ehrcert/EH
  RProductSearch?settingInpatient
• Regional Extension Centers
• http//healthit.hhs.gov/portal/server.pt/community
  /healthit_hhs_gov__listing_of_regional_extension_c
  enters/3519

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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

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Privacy and HIT

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

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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
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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.
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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
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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.

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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

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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.g
  ov/healthprivacy/docs/EHR-FAQs.pdf and
• http//www.samhsa.gov/about/laws/SAMHSA_42CFRPART2
  FAQII_Revised.pdf

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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.

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SAMHSAs 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

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Solutions for Privacy
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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

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Data Standards
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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

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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.

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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

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Quality measurement
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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?

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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 patients
  depression score decrease with treatment)

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SAMHSA Quality Measurement Activities

• Developing clinical quality measures for
  behavioral health that are relevant for the
  meaningful use program

NQF 0109, Bipolar Disorder and Major Depression Assessment for Manic or Hypomanic Behaviors
NQF 0110, Bipolar Disorder and Major Depression Appraisal for Alcohol or Chemical Substance Use
NQF 0111, Bipolar Disorder Appraisal for Risk of Suicide
NQF 1385, Developmental Screening Using a Parent Completed Screening Tool (Parent report, Children 0-5)
NQF 0576, Follow-Up After Hospitalization for Mental Illness
NQF 1401, Maternal Depression Screening
NQF 1406, Risky Behavior Assessment or Counseling by Age 13
NQF 1507, Risky Behavior Assessment or Counseling by Age 18
NQF 0580, Bipolar Anti-manic Agent
NQF 1661, SUB-1 Alcohol Use Screening
NQF 1663, SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB-2a Alcohol Use Brief Intervention
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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

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ADVANCED TOOLS
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BH Treatment Lifecycle
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BH Treatment Lifecycle

• 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

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BH Treatment Lifecycle

• 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

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BH Treatment Lifecycle

• 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

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BH Treatment Lifecycle

• 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

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BH Treatment Lifecycle

• 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

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BH Treatment Lifecycle

• 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

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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

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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

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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.

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SAMHSA HIT GRants
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SAMHSA HIT Activities Expansion Grants

• SAMHSA awarded 29 Targeted Capacity Expansion
  (TCE)-Health IT grants.
• To leverage technology to enhance or expand the
  capacity of substance abuse treatment providers
  to serve persons in treatment who have been
  underserved
• Examples include Web-based services, smartphones,
  and behavioral health electronic applications
  (e-apps).

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SAMHSA HIT Activities Expansion Grants

• SAMHSA has awarded 49 supplemental funds grants
  for Health IT infrastructure for current primary
  and behavioral health care integration (PBHCI)
  grantees.
• To develop infrastructure that supports the
  exchange of health information through EHR data
  systems.
• Sub-awards support sharing of health records
  among behavioral health providers and general
  medical providers through a state HIE (ME, KY,
  IL, OK, RI)
• Technological infrastructure
• Privacy and Security Policies

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Conclusion

• Health IT has the potential to benefit behavioral
  health treatment providers and their clients
  through increased efficiency, coordination, and
  patient engagement.
• 42 CFR Part 2 provides the ability to share
  protected health information, but it is the
  responsibility of the organizations to use that
  information in a way that benefits the health of
  the individuals.
• SAMHSA is working to ensure that providers
  understand the benefits of integrating Health IT
  into their programs and that they have the
  training and tools to support their HIT goals.

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HAVE QUESTIONS?

• Now for your questions...

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Office of the Chief Privacy Officer (OCPO)ONC
Efforts to Maintain the Privacy of Health
Information Protected by 42 CFR Part 2
May 25, 2012 Scott Weinstein, JD
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OCPO Overview

• Chief Privacy Officer position created in HITECH
  Act
• OCPOs responsibilities include
• Advise the National Coordinator on privacy,
  security, and data stewardship of electronic
  health information
• Coordinate with other Federal agencies, State and
  regional efforts, and foreign countries with
  regard to the privacy, security, and data
  stewardship of electronic individually
  identifiable health information

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SAMHSA, ONC-OCPO, and 42 CFR Part 2

• SAMHSA
• Enforces Part 2
• Provides Guidance to Providers on Part 2
  Compliance
• ONC-OCPO
• Working with SAMHSA to explore technologies that
  allow exchange of electronic substance abuse
  clinical information while complying with Part 2

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ONC initiatives that implicate 42 CFR Part 2

• Data Segmentation for Privacy
• Query Health
• SHPC Behavioral Health Data Exchange Consortium
• State HIE Community of Practice Privacy and
  Security Workgroup on 42 CFR Part 2

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Data Segmentation for Privacy Initiative
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Data Segmentation for Privacy Objective

• Produce a pilot project that will allow providers
  to share portions of an electronic health record
  while not sharing others
• Certain privacy laws, such as 42 CFR Part 2,
  already require providers to ensure that parts of
  a medical record will not be shared without
  patient consent
• Data Segmentation for Privacy provides a means
  for electronically implementing choices made by
  patients under these laws
• Several use cases developed that focus on 42 CFR
  Part 2

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User Story Example (1)
? The Patient receives care at their local
hospital for a variety of conditions, including
substance abuse as part of an Alcohol/Drug Abuse
Treatment Program (ADATP). ? Data requiring
additional protection and consent directive are
captured and recorded in the EHR system. The
patient is advised that the protected information
will not be shared without their consent.
?
?
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User Story Example (2)
? A clinical workflow event triggers additional
data to be sent to Provider/Organization 2. This
disclosure has been authorized by the patient, so
the data requiring heightened protection is sent
along with a prohibition on redisclosure. ?
Provider/ Organization 2 electronically receives
and incorporates patient additionally protected
data, data annotations, and prohibition on
redisclosure.
?
?
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User Story Example (3)
? The Patient receives care for new, unrelated
condition and is referred by Organization 1 to a
specialist (Provider/Organization 3).
Organization 1 checks the consent directive and
sends authorized data to Organization 3. ?
Provider/Organization 3 electronically receives
and incorporates data which does not require
heightened protection.
?
?
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Segmentation of medical information

• Determine information covered by Part 2
• Use standardized terminology to express that data
  came from a covered provider (FacilityType)
• Determine if patient has consented to share
  protected information
• Consent refers to documents, document sections,
  or individual data elements that may be sent

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Application of Metadata

• Helps receiving EHR/HIO implement access control
• Electronic enforcement of prohibition against
  redisclosure of information
• Provides a reference to a consent document that
  controls the data

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Query Health
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What is Query Health?

• Objective
• Enable a learning health system to understand
  population measures of health, performance,
  disease and quality, while respecting patient
  privacy, to improve patient and population health
  and reduce costs.

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Improve community understanding of patient
population health
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Summary Query Health Specifications and
Standards

• Query Health must standardize how queries are
  asked, how they are returned, and how the
  information travels between parties.

Specification Definition Standard
Query Envelope A means to package the query and results along with security/privacy requirements, as well as other instructions PopMedNet Query Envelope
Query Format The way in which a query is constructed, its code, vocabulary etc. HQMF- Health Quality Measures Format
Results Format The way in which a result is reported, its code, vocabulary etc. QRDA- Quality Reporting Document Architecture
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Policy Sandbox

• Query requests and responses shall be implemented
  in the pilot to use the least identifiable form
  of health data necessary in the aggregate within
  the following guidelines
• Disclosing Entity Queries and results will be
  under the control of the disclosing entity (e.g.,
  manual or automated publish / subscribe model).
• Data Exchange Data will be either 1) mock or
  test data, 2) de-identified data sets or limited
  data sets each with data use agreements1 or 3)
  a public health permitted use2 under state or
  federal law and regulation.
• Small cells For other than regulated/permitted
  use purposes, cells with less than 5 observations
  in a cell shall be blurred by methods that reduce
  the accuracy of the information provided3.

• Notes
• It is understood that de-identified data sets do
  not require a data use agreement, but in the
  abundance of caution, and unless otherwise guided
  by the Tiger Team or HIT Policy Committee, the
  pilot will have data use agreements for
  de-identified data
• For a public health permitted use, individually
  identifiable health information may be provided
  by the disclosing entity to the public health
  agency consistent with applicable law and
  regulation.
• The CDC-CSTE Intergovernmental Data Release
  Guidelines Working Group has recommended limiting
  cell size to three counts presuming a
  sufficiently large population. This is also
  reflected in Guidelines for Working with Small
  Numbers used by several states.

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Query Health and Part 2

• In future, Query Health technology may be used to
  query identifiable patient information
• Must prevent identifiable Part 2 information from
  being returned in response to a query
• Privacy metadata to restrict information from
  being queryable
• Metadata in query envelope to communicate
  sensitivity when information allowed to be shared

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State Health Policy Consortium (SHPC) -
Behavioral Health Data Exchange Consortium
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Purpose

• Pilot the interstate exchange of behavioral
  health treatment records among treating health
  care providers using Nationwide Health
  Information Direct protocols
• Draft Policies and Procedures (PP) for exchange
  of behavioral health treatment records
• The focus is on meeting the requirements of
  federal regulations at 42 CFR Part 2 and meeting
  mental health laws of consortium states

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Participants

• Consortium States are Alabama, Florida,
  Kentucky, Michigan, Nebraska and New Mexico
  representatives include legal and behavioral
  health subject matter experts
• Each state is to recruit Behavioral Health
  providers and other providers that might exchange
  with Behavioral Health providers to participate
  in the pilots
• Representatives of the ONC, Substance Abuse and
  Mental Health Services Administration, the Legal
  Action Center and subject matter technical
  experts on the NwHIN Direct protocols

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Workflow Scenarios for Discussion
Workflow 2 Update PCP

• Workflow 1 Request for info

• Workflow 3 referral

• At end of patients stay, New Mexico provider
  (who is a Part 2 program and a mental health
  provider) sends patient summary to patients PCP
  in Kentucky

• Florida Part 2 program requests patients records
  from prior stay at Michigan behavioral health
  provider facility (a Part 2 program)

• Alabama PCP sends referral to Florida Part 2
  program

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Workflow 1 Request for Info
Send request for records along with patient
consent
4
Receive request for records along with patient
consent
6
5
HISP
HISP
8
Send patient records specified in patient consent
Receive requested patient records
7
9
Michigan Part 2 Program
Florida Part 2 Program
Jane Patient
3
Signs consent
1
Treatment
Treatment
2
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Workflow 2 Update PCP
5
Sends visit summary and clarifying info
7
6
Receives visit summary and clarifying info
HISP
HISP
3
Jane submits clarifying info
Kentucky Primary Care Provider
Jane Patient
New Mexico Part 2 Program Mental Health Provider
4
Treatment
Signs consent
1
Treatment
2
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Workflow 3 - Referral
3
4
2
HISP
Receives referral
Sends referral
HISP
Jane Patient
Alabama Primary Care Provider
Florida Part 2 Program
5
Future Treatment
Treatment
1
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State HIE Community of Practice Privacy and
Security Workgroup on42 CFR Part 2
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State HIE 42 CFR Part 2 Community of Practice

• Discuss compliance approaches for listing
  entities, including location, formatting, and
  effective business processes for updates.
• Present examples of break the glass access and
  the feedback loop. The focus will be on map
  process requirements, formatting, and
  efficiencies.
• Explain required notices and limitations on the
  re-disclosure of protected information
• Discuss data protection and how data may be
  shareable in a query-based HIE environment

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HAVE QUESTIONS?

• Now for your questions...

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Thank you

• Prepared in 2012 by
• the Legal Action Center,
• under a subcontract from
• Partners for Recovery