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Advancing Primary and Behavioral Health Information Integration within the Behavioral Health Fields

Advancing Primary and Behavioral Health Information Integration within the Behavioral Health Fields. H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services.

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Advancing Primary and Behavioral Health Information Integration within the Behavioral Health Fields

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  1. Advancing Primary and Behavioral Health Information Integration within the Behavioral Health Fields H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services 2011 Health Information Technology Regional forum San Francisco  July 21, 2011

  2. SAMHSA “In 2011, and beyond, SAMHSA will work to improve understanding about mental and substance use disorders, promote emotional health and the prevention of substance abuse and mental illness, increase access to effective treatment, and support recovery.” Excerpt from Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014 Pamela S. Hyde, J.D.Administrator, SAMHSA

  3. SAMHSA’s Role in Improving the Nation’s Health • Behavioral health services improve health status and reduce health care and other costs to society.  • SAMHSA is charged with effectively targeting substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system.  • Continued improvement in the delivery and financing of prevention, treatment and recovery support services provides a cost effective opportunity to advance and protect the Nation’s health. 

  4. Behavioral Health in Primary Care Settings • Illicit drug users are significantly more likely to be treated in emergency facilities or urgent care centers compared with nonusers. • In 2008, in the U.S., over 1.9 million visits to emergency departments were associated with drug misuse or abuse. • Approximately 17% of adults who received outpatient substance abuse treatment received it at a private doctor’s office, another 11% at an emergency room, and 26% at an outpatient mental health center.

  5. Integrated Care • Substance abuse or misuse, mental illness, and physical conditions are intertwined. • Cardiac patients with depression are twice as likely to have medication non-adherence issues. (Gehi, et al., 2005) • An analysis of epidemiological studies revealed 72 conditions (including cardiac and immune system disorders) requiring hospitalization that were wholly or partially attributable to substance abuse. (Merrill, et al., 1993) • Treating the physical illness but ignoring the substance use or mental health disorders is short-changing the patient.

  6. Growth in Number of Health Center Mental Health and Substance Abuse Visits, 2001-2007 More patients with mental health and substance use disorders are seeking treatment in community health centers. 44.8% Increase Since 2001 Source: Federally-funded health centers only. 2001-2007 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Table 5 Lines 20.

  7. Substance Abuse Treatment in 2009 9.2 Million adults (12+ years) seen for substance abuse treatment: 1.6 million seen by Primary Care Source: 2008 NSDUH

  8. Health Reform & Integrated Care Health Reform legislation emphasizes the importance of integrating behavioral health and primary health care. By integrating substance abuse treatment and mental health services into primary care, the quality of health care available to these populations will improve – along with their health status. Effective integration cannot occur without the ability of all entities to share and use information via a common, interoperable IT system.

  9. The Myth of Interoperability A primary care delivery system operating on a web based platform will not be able to communicate with a behavioral health delivery system operating on a paper and pen platform. As the primary care delivery system ramps up under the aegis of the HITECH Act, using systems facilitated by Office of the National Coordinator (ONC) for Health IT and the Centers for Medicare and Medicaid Services (CMS), it is essential for the behavioral health delivery system to follow along.

  10. A Connected Infrastructure with a Behavioral Health Component

  11. Barriers to Integrated Care • Delivery System Design • Physical separation of services, fragmented communication, language differences between systems • Financing • Siloed payment & reporting systems, competition for scarce resources • Legal/Regulatory • HIPAA and confidentiality rules, conflicting mandates at federal, state & local levels, categorical program requirements • Health Information Technology • Lack of common IT systems, electronic health records (EHRs) often unable to support multi-system information Source: Report of the California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (2009, October 22) [PowerPoint Slides] Retrieved from http://www.ibhp.org/index.php?section=news&subsection=show_news_details&news_id=80

  12. Applying Technology to Recovery Health IT can be an asset to integrated care – rather than a barrier. Health IT is more than electronic health records: • Providers and recovery communities need to learn to use technology to deliver prevention and treatment services and • to understand the impact of social networking and technology in general on the nation’s health. • Technology needs to be integrated into the behavioral health workforce.

  13. Summary • Health IT is essential to the transformation of the health care delivery system & the promotion of preventive care and patient self-care – it is the glue that connects the various benefits of health reform. • Through effective use of interoperable HIT systems, patients benefit by more informed care and services, and providers benefit by providing a more comprehensive, cohesive and patient-centered treatment program. • This Regional Forum provides an opportunity to learn more about how Health IT will impact the behavioral health field. • Thank you for participating. I hope you find the next day and a half interesting, challenging, and useful.

  14. Thank you.

  15. SAMHSA’s Strategic Initiative on Health Information Technology H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services 2011 Health Information Technology Regional forum San Francisco, CA  July 21, 2011

  16. SAMHSA’s Strategic Initiatives • Prevention of Substance Abuse and Mental Illness • Trauma and Justice • Military Families • Recovery Support • Health Reform • Health Information Technology • Data, Outcomes, and Quality • Public Awareness and Support

  17. 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.

  18. President’s Vision for Health IT (cont’d) • Quality initiatives will measure performance and drive quality-based competition in the industry. • Public health and bioterrorism surveillance will be seamlessly integrated into care. • Clinical research will be accelerated and post-marketing surveillance will be expanded.

  19. A Connected HIE Infrastructure • Patient-centric design • Disparate IT systems are unified through a shared information architecture • Collaborative Care Model • All providers have access to complete, up-to-date patient information with patient consent

  20. Using HIT to Reduce Redundancy & Improve Quality • One of the goals of Health IT is to improve quality of care. For instance, among the 8.9 million adults aged 18 or older who had any mental illness in the past year and a past year substance use disorder, only 7.4% received treatment for both conditions. (2009 NSDUH) • Interoperable electronic health records provide information that can be shared among multiple participants in an episode of care, including providers, patients, and family caregivers. • Result: improved communication, clearer understanding, and a more integrated and patient-centered treatment.

  21. Using HIT to Better Engage Patients in Care • Health IT increases patient involvement by creating an opportunity to better engage individuals in their care through use of technology which will, in turn, improve health outcomes. • The functionality of interoperable electronic health record (EHR) systems can connect patients to community resources and supports, provide information that permits them to participate in shared decision-making with their clinicians, and support home monitoring of reported symptoms related to chronic conditions with the goal of preventing unnecessary hospitalization. • Integrated and collaborative care has been shown to optimize recovery outcomes and improve cost-effectiveness. (Smith, Meyers, & Miller, 2001; Humphreys & Moos, 2001)

  22. Using Health IT Performance Measures • Health IT performance measures will 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 demonstrate success?

  23. SAMHSA Strategic Initiative - Health Information Technology • Through the Health Information Technology (HIT) Strategic Initiative, SAMHSA is working to increase access to Health IT so that Americans with behavioral health conditions can benefit from these innovations. • SAMHSA works in partnership with the Office of the National Coordinator for Health Information Technology (ONC) to drive innovation and the adoption of HIT and electronic health records (EHRs) to support the transition of specialty behavioral health to interoperate with primary care by 2014.

  24. SAMHSA Health IT Strategic Initiative Goals • Develop the infrastructure for interoperable Electronic Health Records (EHRs), including privacy, confidentiality, and data standards. • Provide incentives and create tools to facilitate the adoption of Health IT and EHRs with behavioral health functionality in general and specialty healthcare settings. • Deliver technical assistance to State Health IT leaders, behavioral health and health providers, patients/consumers, and others to increase adoption of EHRs and Health IT with behavioral health functionality. • Enhance capacity for the exchange and analysis of EHR data to assess quality of care and improve patient outcomes.

  25. Goal: Develop the infrastructure for interoperable EHRs, including privacy, confidentiality, and data standards Objectives: • Actively participate and provide leadership in national forums for the creation of • standard approaches and protocols to protect the privacy of patients and consumers and their confidential information, and • data and outcome measurement standards for behavioral health care. • Provide support to substance abuse and mental health treatment and prevention service providers to participate in health information exchanges. • Ensure that EHR or HIT systems used by SAMHSA or supported by SAMHSA funds conform to national standards or functional certification and interoperability.

  26. Goal: Provide incentives and create tools to facilitate the adoption of HIT and EHRS with behavioral health functionality in general and specialty healthcare settings. Objectives: • Include incentives for the use of EHRs and HIT in SAMHSA grants • Facilitate the dissemination of information on the acquisition and effective use of EHRs and HIT to the behavioral health community. • Facilitate the development of a standardized patient encounter form for Screening, Brief Intervention, Referral, and Treatment (SBIRT) protocols used in primary care, specialty behavioral health, and numerous medical facility applications

  27. Goal: Deliver technical assistance to State HIT leaders, behavioral health & health providers, patients & consumers, & others to increase adoption of EHRs & HIT with behavioral health functionality. Objectives: • Educate and train behavioral health constituent groups on the options for including State laws, 42 CFR Part 2 protections, and mental health privacy within the EHR and HIE environment • Educate and train patients and consumers, especially those in recovery, on the options for including 42 CFR part 2 protections and mental health privacy associated with State laws within the EHR and HIE environment.

  28. Goal: Deliver technical assistance to State HIT leaders, behavioral health & health providers, patients & consumers, & others to increase adoption of EHRs & HIT with behavioral health functionality. Objectives (cont’d.): Assist local groups and regional extension centers in outreach and communications efforts within the provider community and the public. Work with the State HIT coordinators to ensure the close coordination of federally and State-funded HIT initiatives, especially within the behavioral health community. Add geographic information system (GIS) capacity to the operations center for SAMHSA National Suicide Lifeline and Veterans Administration Suicide Prevention Hotline. 30

  29. Goal: Enhance capacity for the exchange and analysis of EHR data to assess quality of care and improve patient outcomes. Objectives: • Ensure that behavioral health data can be exchanged on a local, regional, State, and national basis. • In consultation with State and national experts, develop standards to assess the quality of care and patient outcomes. • Establish uniform reporting requirements across all grantees and other federally funded behavioral health initiatives to ensure effective analyses of data on the quality of care and patient outcomes.

  30. HIT Activities: HIT Supplements to PBHCI • SAMHSA has developed 2 RFA’s for distribution of supplemental funds for Health IT infrastructure development ($15 million total): • 1 for current Primary and Behavioral Health Care Integration grantees ($11.2 Million) – applications due 6/20/11. • 1 for States and technical assistance to states and grantees (single source to National Council for Community Behavioral Healthcare ($3.8 Million) • Objective of RFAs: to incentivize state designated entities and PBHCI grantees to develop infrastructure supporting the exchange of health information through the development or adaptation of EHR data systems. 32

  31. HIT Activities: Grants to Expand Care Coordination through the Use of Health Information Technology in Targeted Areas of Need • SAMHSA has developed a TCE-HIT grant to provide $5.6 million in funds to leverage technology to enhance and/or expand the capacity of substance abuse treatment providers to serve persons in treatment who have been underserved because of lack of access to treatment due to transportation concerns, an inadequate number of substance abuse treatment providers in their community, and/or financial constraints. (Applications due 6/16/11) • Examples of capabilities that could be developed with the funds include web-based services, smart phones, and behavioral health electronic applications (e-apps). • Grantees will use technology that will support recovery and resiliency efforts and promote wellness. 33

  32. HIT Activities: 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 a set of Frequently Asked Questions (FAQs). These FAQs can be accessed at: http://www.samhsa.gov/healthprivacy/docs/EHR-FAQs.pdf SAMHSA is currently creating a second set of 42 CFR Part 2 FAQs as a result of input received from stakeholders that expands the existing FAQs to include additional confidentiality areas and situations. Both documents are developed by the Legal Action Center. 34

  33. HIT Activities: Interdepartmental Task Force on Privacy and Security SAMHSA is participating in interdepartmental task force led by DHHS Deputy Secretary, Bill Corr to address privacy and security regarding Health IT and EHR. Meetings will include the following topics: Scope of Privacy Protections Choice to Share Information Restrictions on Access and Transparency Security Safeguards 35

  34. HIT Activities: Collaborations • Collaboration with Centers for Medicare and Medicaid Services re. preparation for the conversion to ICD-10 • SAMHSA is working with CMS to identify and track SAMHSA and its grantees re. preparation for the transition to ICD-10 diagnostic and procedures billing codes. • ICD-10 transition date: 10/1/2013 • Collaboration with Department of Army • Purpose: to extend the content and functionality of an existing Dept. of Army project to incorporate SAMHSA substance abuse and mental health facility electronic records and related crisis centers into the existing Geographic Information System (GIS). 36

  35. HIT Activities: Collaborations (cont’d.) • Collaboration with NIH on a quality measure definition process • Participation in HL7 Reference Information Model Based Application Architecture working group to present information related to the SAMHSA Open Behavioral Health Information Technology Architecture (OBHITA) project • SAMHSA is investigating a collaboration with FCC regarding behavior health and Broadband in rural communities. 37

  36. Additional HIT Activities in Support of Goals SAMHSA is working with: Several State behavioral health and Medicaid agencies to develop open source EHRs and health information exchange (HIE) services that integrate behavioral health within community-based health homes and State Health and Human Service programs. The treatment field to develop a web-based system that would provide digital access to medication, including selected patient health information and dose levels, that can be securely accessed by providers nationwide. This system is being developed to address the need for continued care of opioid-dependent patients displaced by various disasters. 38

  37. Health Information Technology Goes Beyond EHR • Beyond the increased emphasis on interoperable EHR systems, the behavioral health field needs to be ready for the sweeping changes that technology brings: • The ability to identify new substances and exploit existing ones to trigger a euphoric or psychedelic effect (salvia, K2, bath salts) • The effect of social networking to get the message out, exchange information, build a community of users. • The ability to connect with suppliers throughout the world, who promise anonymous or discreet packaging and accept cash transfers.

  38. Behavioral Health E-Applications • There are over 100 consumer behavioral health e-applications developed to be used on a variety of different platforms, including via the Web, messaging systems, PDAs, and cell phones • These applications assist with: • self-management through reminders and educational prompts, • delivering real-time data on a patient's health condition to both patients and providers, • facilitating Web-based support groups, and • compiling and storing personal health information in an easily accessible format. • In addition to convenience, applications also can be important in emergency situations to provide critical health information to medical staff. 

  39. A-Chess • SAMHSA is testing a smartphone-based recovery tool -- called Addiction Comprehensive Health Enhancement support System (A-Chess) -- that features: • Online peer support group & 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.

  40. HHS/ONC Introduce Program to Encourage Innovation in Health IT • On June 8, 2011, ONC announced the Investing in Innovations (i2) Initiative, which conducts competitions and awards prizes to accelerate the development of solutions and communities around key challenges in Health IT. • Examples of competition topics include tools that allow individuals to customize the privacy of their personal health records and applications that allow individuals to securely share health information within their social networks. • The goal is to encourage the development of tools and applications that increase the effective use of health IT. • More information is available on the ONC website: www.healthit.hhs.gov.

  41. Summary • Health IT is essential to the transformation of the health care delivery system & the promotion of preventive care and patient self-care – it is the glue that connects the various benefits of health reform. • Behavioral health IT, linked with health IT in general -- through electronic health records and other technologies -- will allow for the documentation of effectiveness, efficiencies, and quality of care. Thank you.

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