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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 provider

network, 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 the

engagement 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 2

Consent 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.

Leverage technology to enhance or expand the

capacity 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 App

o 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&I

Framework 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 beginning

Technology 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.

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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

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Contact: Kate.Tipping@samhsa.hhs.gov

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