Welcome to the Behavioral Health Data Sharing Toolkit!
These case studies are reproduced from the the California Healthcare Foundation report prepared by Manatt, Phelps & Phillips, LLP: Fine Print: Rules for Exchanging Behavioral Health Information in California. In the initiatives described here, mental health treatment data are made available to physical health providers, although each initiative is using a different methodology for data sharing and patient consent. All three continue agree that data sharing and communication create the foundation for a team-based approach to coordinated mental and physical health care. Despite progress, challenges remain in sharing substance abuse treatment data and incorporating data sharing protocols into existing provider workflows and operations.
Each of these initiatives:
- requires additional steps outside of an EHR system to make information available and subsequently to access it.
- recognizes that barriers to information sharing go beyond the legal and the technical.
Case Study Highlights
Mental health information can be shared by California health care providers for treatment and care coordination, although providers are using somewhat different pathways to achieve these goals. Which option works best may depend on legal interpretations of counsel and providers’ comfort about sharing information without necessarily first obtaining consent.
None of these initiatives has achieved seamless digital sharing of mental health information across disparate providers, largely due to the lack of interoperability of EHR technology. Federal regulators are working to try to resolve the lack of interoperability among EHR systems, but local regions are actively developing workarounds to get information moving to support integrated mental and physical health care.
This was a coalition of 16 private, nonprofit clinics that provide primary care and behavioral health services to one in six San Diego County residents. The coalition has had initiatives to integrate behavioral and physical health care in place for nearly a decade, which began with a county contract, supported by funding from the California Mental Health Services Act (MHSA). Integrated care in San Diego started with embedding behavioral health professionals in FQHCs to address the behavioral health needs of their patients. Funding was then procured from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to do “reverse integration,” embedding primary care professionals in behavioral health programs to screen patients receiving specialty mental health treatment for serious physical illnesses, with a goal of reducing the 25-year mortality disparity for people with severe mental illness.
Inland Empire Health Plan (IEHP) is a Medi-Cal managed care plan serving San Bernardino and Riverside Counties. IEHP recognizes the importance of integrated behavioral and physical health care; it is one of the first health plans to have a behavioral health department. To enable this integrated care, IEHP has created a secure portal where behavioral health care providers can deposit treatment plans, which include medication lists, for those beneficiaries for whom IEHP is the primary payer for behavioral health services. The beneficiaries’ other treating providers can then view, download, or print those plans. To date, the portal supports one-way sharing of information from behavioral health care to physical health providers. It is separate from the providers’ EHR systems; consequently, action outside of the EHR is required by both types of providers to assure the information is uploaded and subsequently accessed.
Alameda’s data sharing initiative focused on individuals with severely mentally illness who frequently have chronic medical conditions and poor health outcomes. To address this health disparity, the county launched the “10 by 10” campaign in 2012 aimed at increasing life expectancy for mental health consumers by 10 years within 10 years. Alameda County has access to claims data for uninsured people because the county pays for their care. Under this initiative, providers exchange only data that can be shared legally in California without consent or authorization of the patient.
Mental Health Data
- Each initiative enables sharing of mental health information across disparate entities
- Alameda County has analyzed federal and California law and advised that the sharing of mental health information can take place without the need for consent
- CCC’s data-sharing initiatives rely on obtaining patient consent for such sharing
- IEHP’s sharing portal requires behavioral health providers to attest that they have obtained the required consent from the individual prior to sharing information through the portal
- CCC clinics are faxing information across entities, or nurses in one of the pilots are developing shared treatment plans in telephone conversations
- In Alameda County, specialty mental health providers upload flat files, which are processed and turned into Excel files and made available to a patient’s physical medical home provider on a secure server
- IEHP supports a secure portal that enables behavioral health providers to upload documents for physical health providers to access
Substance Use Data
Substance abuse treatment information, whether from a program covered by Part 2 or by California law, is either not being shared in these initiatives, or the sharing of that information is not actively promoted.
The Part 2 prohibitions on re-disclosure without authorization, as well as the requirement to obtain authorization that is specific to a provider organization — and the reliance of California regulations on Part 2 — make sharing this data particularly difficult.
Whether consent of the patient is sought prior to such data sharing varies by initiative.
CCC does not seek individual consent for data sharing in its initiative because the embedded professionals are considered to be internally accessing information on-site, while Riverside County has approved a consent form to support this sharing.
- The sharing of data under one initiative took place by giving the participating professionals staff credentials to access the medical records used at the facility or location where care was provided. This sharing occurs largely through faxes between mental health providers and primary care entities, mostly FQHCs.
- In one initiative, providers exchange only data that can be shared legally in California without consent or authorization of the patient. According to Alameda County officials, these data include:
- The same broad scope of information from mental health providers, because California law permits this information to be shared with other health care providers who have “medical or psychological responsibility for the patient.”
- Information from general health care providers, including information about mental health, HIV/AIDS and other sexually transmitted diseases, because HIPAA and California law permit this information to be shared.
- Although most of the data that has been shared to date has been about adult patients seen by specialty mental health providers, providers are expanding data sharing to adolescent patients. County counsel has advised that the mental health data of minors can be shared with treating providers as part of care coordination.
- San Diego clinics use a consent form approved by county counsel that the individual executes either upon discharge from a mental health facility, or as part of a care transition. (See the San Diego Consent Form.) The form covers the sharing of data between a designated mental health provider or provider organization and a designated physical health provider or provider organization.
- Patients are required to identify the particular types of data that are allowed to be shared. In circumstances where patients do not sign this consent to share information, no data or information is shared.
- In two other of the San Diego integration pilots, patients execute a short, one-page consent form that enables the sharing of data between the specialty mental health provider, the FQHC, and the clinic consortium (which collects and analyzes the data). (See the Blue Shield Consent Form.)
- Providers that serve as a “medical home” for assigned patients can scan or manually enter treatment plan and other health and behavioral health information into the Electronic Health Record. With a similar focus on care coordination, acute psychiatric hospitals are sharing discharge summaries with patients’ designated medical homes, although this is not occurring as consistently as the sharing of ambulatory care information.
- Providers in Alameda County rely on a policy matrix approved by the County counsel to guide their actions regarding cross-sector data sharing. (See the Alameda Policy Matrix.) Although leadership in Alameda County has endorsed this approach, and information sharing with medical homes is occurring, there are ongoing discussions among clinical professionals and patient advocates about what role patient consent should play in authorizing the sharing of this data, even in circumstances where it can be legally shared without express consent. There are concerns about stigma, and disagreements over whether those concerns are best honored by providing patients with choices about sharing sensitive data or exacerbated by treating this information as more sensitive than other health information.
- When IEHP contracted behavioral health providers upload a treatment plan to the portal, they also are required to attest that they have the consent of the beneficiary to share the plan with other treating providers. IEHP allows a beneficiary’s treatment plan to be accessed by any health care provider that has established a treatment relationship with the patient (i.e., the patient is linked to that provider). IEHP makes a consent form available for behavioral health providers to use with patients, but those providers are free to use their own processes instead. (See the IEHP Consent Form.)
- When beneficiaries decline to give consent for access to their behavioral health treatment plans, the plans are still uploaded into the portal to process payments from IEHP, but are blocked to other treatment providers. In IEHP’s experience, such access blocks are infrequent. IEHP is also working with Riverside County to embed behavioral health professionals in primary care clinics. The county has developed a consent form that individuals execute to enable sharing of mental health treatment information and HIV test results with specific health care providers or organizations. (See the Riverside Consent Form.)
Challenges and Limitations
- Information is being shared on paper, as behavioral health EHR systems often do not interface with EHR systems used by other health care providers. As a result, summary-of-care documents generated by physical medical providers, such as those participating in the federal EHR incentive program, cannot be shared by or with mental health providers.
- Although the completion of a consent form provides a level of comfort that such sharing is in compliance with applicable law, getting providers to actually share information and communicate with one another is another challenge. Traditionally, payment streams for mental/behavioral health and for physical health have been separate, and currently neither system rewards or expressly pays for care integration or coordination.
- Although medical providers receive an email indicating that a behavioral health treatment plan is available for their patients, use of the portal by such providers has been fairly limited. IEHP speculates that the reasons for this are:
- consulting an outside portal, even for care coordination, is not well integrated into providers’ existing workflows
- there are insufficient financial incentives to motivate the extra effort needed
- providers’ medical record technology is unable to incorporate the care plans, possibly requiring the information to be kept in paper form, scanned, or manually uploaded into a treating provider’s EHR.
- Initiatives do not involve the sharing of information covered by state or federal substance abuse treatment regulations because of their additional restrictions on data sharing.
- Sharing substance use treatment data through the IEHP portal — or even by fax if the portal is not used — typically occurs only if the substance abuse treatment provider and the physical health provider have conferred to discuss the patient, have agreed in advance to share data, and have agreed to share only data that are not covered by Part 2.