Kate Tipping, J.D. Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services
Health Information Technology
and Behavioral Health
Annual Summit on Telehealth Technologies A Forum for Telehealth Innovations
National Frontier and Rural ATTC August 26, 2014
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Medical information will follow
consumers so that they are at the center of their own health care.
Consumers will choose providers and
hospitals based on clinical
performance results available to them.
Clinicians will have an individual’s
complete medical history,
computerized ordering systems, and electronic reminders to improve
quality of care. President Barack Obama
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Today’s Behavioral HIT Topics
Improving Practice Protecting Privacy SAMHSA’s Solutions
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Improving Practice Protecting Privacy SAMHSA’s Solutions
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Interoperable HIT for Seamless, Integrated,
Comprehensive Health Care
Hospitals Pharmacies, PDMPs 6 Community Services Insurance Providers Substance Abuse Treatment Programs Primary Care Mental Health Services Consumer Centric Health Information Exchange
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U.S. National HIT Landscape
HITECH Act: Large national investment in HIT;
largely excludes BH providers.
Health Reform & the ACA: Coordinated,
integrated, client-centered care; expanded consumer base & transformation of service delivery and payment models; MHPAEA.
Privacy and Confidentiality Regulations: HIPAA;
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Improving Practice:
SAMHSA’s Behavioral HIT Strategic Initiative
Ensure that the behavioral health providernetwork, including prevention specialists and consumer providers, fully participates with the general health care delivery system in the
adoption of health information technology.
Support the behavioral health aspects of the
electronic health record based on the standards and systems promoted by the Office of the
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SAMHSA’s Behavioral HIT Objectives
Increase the involvement of BH organizations and
providers in HIT initiatives including Health
information Exchanges (HIE), EHRs, and PDMPs.
Increase the number of BH organizations meeting
meaningful use activities.
Address the issues of privacy and security
associated with mental illness and substance use disorder treatment.
Expand working relationships & collaborations
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SAMHSA’s Behavioral HIT Goals
Develop infrastructure for interoperable EHRs, including
privacy, confidentiality, and data standards.
Support initiatives to develop/expand interoperability
between various data systems including HIEs, EHRs, and PDMPs.
Provide incentives and create tools to facilitate the
adoption of HIT with behavioral health functionality in general and specialty healthcare settings.
Deliver technical assistance to State Health IT efforts;
behavioral health providers; & and other stakeholders.
Enhance HIT capacity, functionality, and accuracy to
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The Role of Health IT
Health Information Technology is an important part of
providing integrated treatment by linking between 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
• Improve the quality of care
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Examples of SAMHSA Behavioral HIT Projects
Collaborations with public & private partners to
enhance & expand HIT capacity & interoperability.
TCE-Technology Assisted Care Grants.
Grants for OTPs to adopt or upgrade to certified
EHRs.
Incorporating HIT into SBIRT.
Using new media to prevent Substance Abuse &
HIV/AIDS.
Mobile App Challenges.
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Using HIT to Increase BH Client Engagement
HIT has tremendous potential to increase theengagement of BH clients in their own care.
• Provide individuals with health information tailored to their own risks and health literacy
• Provide links to community and online resources
• Provide tools to support self-care & shared decision making
– Goal setting and tracking – Supporting adherence
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Applying HIT BH Performance Measures
HIT BH performance measures 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?
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Behavioral HIT Stakeholder Engagement
SAMHSA held three HIT Regional Forums:• Participants were from 50 states and U.S. territories.
• Objective: facilitate the integration of standards-based HIT within the behavioral health field.
SAMHSA also met with various stakeholders
regarding behavioral health electronic records & performance measures (APA, ASAM, NAADAC, NASADAD, NASMHPD, etc.)
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Behavioral HIT Stakeholder Concerns
Matching evolving business practices with evolving
trends in treatment.
Interoperability (e.g, compatibility of legacy
systems w/newer systems).
Not having the ability to receive Meaningful Use
incentives.
Smaller practices lack the funds to be able to
successfully implement EHR.
Lack of resources to properly educate staff on the
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Behavioral HIT Challenges
How should HIT systems be designed to control disclosure
and re-disclosure of BH sensitive information?
How can we ensure that when BH data are shared they
are interpretable across providers and by third parties (e.g., researchers, public health, surveillance)?
How can BH systems evolve rapidly along with research
and changing best practices?
How can new technologies take us to the next level of BH
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Behavioral HIT Challenges (cont.)
How can technologies be used to reduce BH reporting
burdens while improving data quality? • Minimize data re-entry
• Harmonize across programs to data elements collected
in the normal course of care delivery
How can BH systems share information with other service
agencies? For example: • Criminal Justice
• Housing and Urban Development
• Local & Regional Public Health and Social Services Agencies
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Improving Practice Protecting Privacy SAMHSA’s Solutions
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HIT & BH Privacy
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Confidentiality and Trust
In order to achieve any level of systemic durability
and success, HIT must be trustworthy and
developers and managers must warrant & sustain trusting relationships with all participants, especially the public consumer.
Privacy is not an area for compromise
Confidentiality should never be a shortcut Security should not be a second thought
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Consent cannot be valid if people can only
obtain essential services by providing it.
Forced Consent is Not Consent
Br J Gen Pract. 2004 September 1; 54(506): 725 ;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1326097/pdf/bjpg54-725.pdf
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Privacy & Technology:
Partners or Adversaries?
Data integration and aggregation, coupled with
increased on-line accessibility and sophisticated hacking, tracking, and data mining technologies, dramatically increase the risk and the
consequences of breaches of privacy and confidentiality.
In turn, these elevated risks & consequences
dramatically increase our obligations to ensure consumer choice; privacy & confidentiality; state-of-the science security; and rapid mitigation of unintended consequences.
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Purpose of 42 CFR Part 2
The purpose of 42 CFR Part 2 and other
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.
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42 CFR Part 2 Applies to Federally
Assisted Services
Applies to federally assisted individual or entity
that “holds itself out as providing, and provides,
alcohol or drug abuse diagnosis, treatment or treatment referral”.
• Unit within a general medical facility that
holds itself out as providing diagnosis,
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Federal Privacy Regulations
Patient consent must be obtained before sharing
information from a substance abuse treatment facility that is subject to 42 CFR Part 2 or Title 38 (VA)
Prohibition on re-disclosure without consent
Not intended to prevent information sharing but to
set standards on how to share patient information
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42 CFR Part 2
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
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42 CFR Part 2 Public Listening Session
SAMHSA held a Public Listening Session on Wednesday, June
11, 2014 to solicit information concerning potential changes to the Confidentiality of Alcohol and Drug Abuse Patient
Records Regulations, 42 CFR Part 2.
Federal Register Notice of Meeting:
https://www.federalregister.gov/articles/2014/05/12/2014- 10913/confidentiality-of-alcohol-and-drug-abuse-patient-records
Comments were due Wednesday, June 25, 2014 Comments are under review
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42 CFR Part 2 Public Listening Session Topics
Applicability of 42 CFR Part 2Consent requirements Redisclosure
Medical emergency provisions Quality Service Organization
(QSO) provision
Research
Electronic prescribing and
PDMPs
https://www.federalregister.gov/articles/201 4/05/12/2014-10913/confidentiality-of-alcohol-and-drug-abuse-patient-records#h-8
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Part 2 Listening Sessions Available on
YOUTUBE
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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.gov/healthprivacy/docs/EHR-FAQs.pdf and
http://www.samhsa.gov/about/laws/SAMHSA_42CFRPART2F
AQII_Revised.pdf
Series of webinars by the Legal Action Center on 42 CFR Part 2
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Mental Health Confidentiality
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
EHR systems have to recognize this variability in
state statutes and regulations.
State laws also often provide additional protections
for HIV infection, genetics, minors, domestic violence, reproductive health etc.
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Privacy & Best Care Possible: Ensuring Synergy
Consumer-centric HIT
• Consent management: Consumer regulates
access (privacy, confidentiality)
• Data segmentation & security
Consumer HIT education & engagement
HIT transparency, accountability, & consistency HIT consumer alert systems
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Improving Practice Protecting Privacy SAMHSA’s Solutions
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SAMHSA’s Behavioral HIT Portfolio
Since FY2010, SAMHSA has awarded over $43
million in funds for HIT projects and programs.
Approximately 54 grants have been awarded
between FY2010 and FY2014.
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States with SAMHSA Funded HIT Grants
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SAMHSA’s HIT Portfolio is Diverse
SAMHSA’s HIT portfolio bridges a range of strategies:
e-therapy, telehealth, e-Recovery, EHR systems, a Virtual Reality Clinic, Smartphone technology, web-base virtual recovery, telephone counseling,
telepsychiatry, automated wellness calls, pre-admission web-portals, and mobile strategies.
• Projects focused on underserved populations such
as individuals living with HIV/AIDS in rural areas • Projects focused on vulnerable, high-risk
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SAMHSA’s TCE-TAC
Targeted Capacity Expansion (TCE) Technology
Assisted Care (TCE-TAC) Grants enables SAT programs to:
• Expand care coordination through the use of HIT.
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Leverage technology to enhance or expand thecapacity of substance abuse treatment
providers to serve persons in treatment who are underserved.
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Reducing the Human Toll:
SAMHSA’s OTP-CoC Initiative
Enhancing Opioid Treatment Program Patient
Continuity of Care through Data Interoperability.
Purpose: to provide resources to opioid
treatment programs (OTPs) that will enable them to develop EHR systems that fulfill
regulatory requirements, achieve certified
status, and become interoperable with other patient health record systems.
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EHRs and PDMPs
Electronic Health Record (EHR) and
Prescription Drug Monitoring Program
(PDMP) Data Integration Project
• Purpose: to link EHRs and pharmacy dispensing systems to PDMPs.
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SAMHSA’s Current HIT Projects
Cooperative Agreements for Screening, Brief Intervention and
Referral to Treatment (SBIRT)
• Up to 30% of funds can be used for HIT infrastructure development to support efficacy and sustainability of SBIRT program (EHR implementation, Telehealth, HIE integration, tablet based screening, web portals, etc.)
Open Behavioral Health Information Technology Architecture
(OBHITA) project
• Open Source, modular technology that can be integrated into existing EHR systems: Consent management and data segmentation, clinical decision support, patient
assessments
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SAMHSA Quality Measurement Activities
Currently, SAMHSA is working with technical and
clinical experts to develop additional quality
measures to support integrated care for co-occurring disorders.
• E.g. diabetes and CVD screening in patients with SMI
We are also working to promote the inclusion of
additional behavioral health related quality measures in Meaningful Use Stage 3.
• Composite measure for substance use screening
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Health Care Integration:
SAMHSA’s HIT Collaboration with HRSA
5 Sub-awards supported sharing of health records among behavioral health providers and general medical providers through state HIEs (ME, KY, IL, OK, RI)
Develop infrastructure supporting the exchange of health information among behavioral health and physical health providers
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Identify barriers to inclusion of behavioral
health in state HIEs.
Identify technology and policy solutions for
compliance with federal and state regulations.
Develop a consent form template that is
computable in a HIE Environment.
Primary challenge around technical capacity
for consent management.
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The ASAM Patient Placement Criteria (PPC) is a
multi-dimensional patient assessment tool linked to a
comprehensive set of clinical decision support guidelines for patients with addiction disorders.
• Provides evidence based recommendations for level of
treatment required
SAMHSA worked with ASAM to develop a web service for
the ASAM PPC which can be integrated with existing EHR systems.
• Pilot testing is ongoing
• Software will be free and publicly available
Clinical Support Tools:
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New Media & High Risk Populations:
SAMHSA’s Minority AIDS Initiative
Minority AIDS Initiative (MAI) Program: Using
New Media to Prevent Substance Abuse & HIV/AIDS for Populations at High Risk.
• Utilizing new media to promote targeted SA and HIV prevention messages to selected
racial/ethnic populations at high risk for SA and HIV infection.
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Mobile Technology:
SAMHSA’s Mental Health App
Mental Health Recovery Appo Developing technical specifications for a
mobile app to support patients in recovery from mental disorders and co-morbid
substance use disorders
Developing mHealth policy
o Endorsement/certification and
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Mobile Technology:
SAMHSA-Supported A-CHESS App
Addiction- Comprehensive
Health Enhancement Support System (A-CHESS)
• Connection with a support team (other ACHESS users)
• Photo sharing, discussion group and healthy event planning
• Use of GPS to detect when user is near a high-risk location (for
example, a liquor store)
• Video chat with counselor or discussion group
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SAMHSA’s Prevent High-risk Drinking among College
Students Challenge:
• Prevent high-risk drinking among college students
through cost-effective, portable, technology-based products.
• Products to effectively reach college students, parents,
administrators, faculty, and staff.
– BeWise (Syracuse U.)
– Expectancy Challenge Alcohol Literacy Curriculum
app (University of Central Florida)
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SAMHSA’s Primary Care Suicide Prevention App Challenge
• Assist in delivering evidence based practices to primary
care providers whose patients present with suicidal ideation
• Develop mApp that provides care continuity and
follow-up linkages for someone at risk for suicide who was discharged from an inpatient unit or emergency department.
– Relief Link , Emory University
– MyPsych
– ReachZ & Companion
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Advanced Solutions for Privacy
SAMHSA has been working with the ONC S&IFramework and the VA to develop open source technology for consent management and data
segmentation to give the consumer granular control over information sharing. Support compliance with 42 CFR Part 2, Title 38, and state health privacy laws
Open source tool that is being designed to integrate
into existing EHR and HIE platforms
http://wiki.siframework.org/Data+Segmentation+for
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Consent2Share
Real world pilot tests:• One state HIE, Prince Georges County Maryland,
enabling exchange between a Part 2 program and a primary care organization
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Solutions for Privacy
Need to develop community consensus on how to
define sensitive information (i.e. what information should be redacted if a patient doesn’t want to share their substance abuse or HIV information)
Need to communicate the benefits and risks to the
patient very clearly
SAMHSA is working with community experts to
develop consensus in these areas through health level 7 (HL-7)
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SAMHSA HIT Standards Development
SAMHSA has been 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)
•
http://wiki.hl7.org/index.php?title=Community-Based_Collaborative_Care
We are also working with the ONC S&I workgroups for Long
term coordination of care and Transitions of care to ensure that behavioral health information is included and aligned with the data standards in the BH-CCD
http://wiki.siframework.org/Transitions+of+Care+%28ToC
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Closing Thoughts:
The Future of Behavioral HIT
The HIT revolution is just beginningTechnology is evolving rapidly
Many of the tools that are being used now will
be displaced by newer tools that support
safer, higher quality, more efficient workflow
Focus needs to be on long term potential for
improving health care services and delivery through HIT and other innovative
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Lessons Learned Thus Far
Transitioning to new technologies takes patience. In rural areas, the lack of technology infrastructure
to provide requisite bandwidth for operation of telehealth equipment limits our ability to reach telehealth goals.
Inflexible business relationships with vendors locks
in programs to proprietary systems, which can prevent/impede adoption of more appropriate technology.
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Provider reluctance to adapt to the use of
innovative technologies.
Staff reluctance to adapt to the use of new
technologies.
Limited patient access to the internet and to
smartphones.
Patient/client resistance.
58 Looking Forward:
Behavioral Medicine & the Web Data Revolution
Could Behavioral Medicine Lead the Web Data
Revolution? Ayers et al. JAMA 2014.
Billions of digital footprints from nearly all
parts of the United States and from countries around the world provide a powerful
opportunity to expand the evidence base across medicine.
• Behavioral medicine can be a leader in this web data revolution
Contact: Kate.Tipping@samhsa.hhs.gov