Welcome to the Behavioral Health Data Sharing Toolkit!
SUMMARY
Developing the technology for appropriate data systems that support and facilitate the transfer of patient information across providers and systems is a central feature of an integrated approach to care. Systems that can easily and securely provide that function are not yet fully realized for most providers and communities. In this section, the technology challenges and state of information sharing discussed in the Manatt, Phelps & Phillips, LLP: Fine Print: Rules for Exchanging Behavioral Health Information in California are explored.
Beyond technology mechanics however, meaningful coordination between behavioral health and primary care organizations requires tracking individual patients within and across systems, sharing and exchanging information in real-time, and accessing information in clinically informative and usable ways. We include in this section a discussion of the characteristics of High Functioning Clinical Information Systems that support integrated, coordinated care and have identified 3 core areas for consideration: Functionality, Data & Clinical Content, and Implementation.
Characteristics of High Functioning Clinical Information Systems that Support Integrated, Coordinated Care
Implementation of the Patient Protection and Affordable Care Act of 2010 (ACA) has accelerated a shift toward greater accountability and efficiency in the health care system using information technology and data. As integrated care approaches are implemented across health and behavioral health care settings, the need for data systems to support and track both health and behavioral health data is essential.
A critical tool to support cross-system data sharing and care coordination for person-centered care is a clinical information system, or CIS. The MacColl Institute for Healthcare Innovation offers the following description of a Clinical Information System:
“Effective chronic illness care is virtually impossible without information systems that assure ready access to key data on individual patients as well as populations of patients. A comprehensive clinical information system can enhance the care of individual patients by providing timely reminders for needed services, with the summarized data helping to track and plan care. At the population level, an information system can identify groups of patients needing additional care as well as facilitate performance monitoring and quality improvement efforts.” (See this link for more.)
Historically, Clinical Information Systems have been designed for use in single provider settings, not to support multi-agency, data sharing processes. However, much of the core architecture and functionality of a CIS can be leveraged to support the added complexity of cross-system data sharing and service coordination between separate entities, including primary care and behavioral health providers.
While providers may achieve some improved coordination through the use of their local CIS, developing systems that coordinate across providers and organizations will require a broader commitment and investment to support data sharing by the range of stakeholders potentially involved, including health plans, hospitals, primary care, mental health, and substance use treatment providers.
Meaningful coordination between behavioral health and primary care organizations requires tracking individual patients within and across systems, sharing and exchanging information in real-time, and accessing information in clinically informative and usable ways.
Recommendations for how Clinical Information Systems can support data sharing & care coordination fall into three core areas:
Functionality
A highly functioning CIS can promote care coordination and data sharing across the medical, mental health and addiction treatment sectors by having the functionality below.
Data and Clinical Content
CIS core functionalities will only be useful if relevant information for integration of MH/SUD is routinely and systematically captured. Given the diversity and complexity of patients with MH/SUD and other chronic conditions, a CIS must be able to capture and track a wide array of data. To effectively support care coordination and MH/SUD integration, the following additional data elements are recommended for the established categories below.
Implementation Considerations
Increased functionality and expanded data and clinical content do not ensure that a CIS will be used effectively to support data sharing and coordination of behavioral health and primary care services. Key factors to support positive adoption of a CIS include leadership and oversight, clinical and operational processes and collaboration across the medical and behavioral health sectors.
Functionality
- Communication and Information Exchange: A CIS should promote and support cross system communication and information exchange to support patients and clients. Population-based analytic software or registries need to pull data from multiple EMRs to analyze and present data in a meaningful way to provider teams that span multiple sectors. In addition, CIS need to support communication and exchange of information among individual providers, hospitals, and health plans as well as communication with patients regarding changes in condition, questions about treatments or side effects, care coordination needs, and other issues.
- Security: Exchange of information can only be successful when appropriate controls are in place for protecting the privacy of individuals’ personal health information. A CIS must have highly flexible and specific privacy controls to support both individual preferences of security and relevant laws and regulations. For example, to address confidentiality policies such as HIPAA and 42 CFR Part 2 , a CIS should track release of information and client consents, and open or close access according to individual patients’ preferences.
- Ease of Adaptability, Access and Use: To support real-time, clinical use of data by individual providers, a CIS must be easy to use and provide clinical and operational performance dashboards to track measures and improvements. Analytic reports must be accessible to anyone on the multidisciplinary care team whether on-site or located at another organization.
- Shared Care Planning: Fundamental to care coordination is shared care planning. A CIS can support collaborative planning and facilitate access to a shared care plan across both behavioral health and primary care providers by incorporating permission settings based on patient consent. Shared care plans can include names and contact information for care team members, patient goals and advanced directives.
- Treatment Reconciliation: Providers who care for complex clients need access to comprehensive information to assure their treatment supports complement and do not conflict with the treatment recommendations of other providers and vice versa. A common example of this is medication reconciliation, a process that is facilitated by a CIS. Given the interactive nature of physical, mental and substance use disorders, this reconciliation process applies to all types of treatment, regardless of its modality or provider.
- Clinical Prompts and Flags: A CIS can provide prompts or flags to facilitate effective, timely treatment and coordination of care. Auto-prompts should be designed to allow for quick prioritization of clinical needs and improve the efficiency of the encounter. Examples of prompts that support coordinated care include:
- Prompts for primary care providers that trigger a behavioral health referral for patients with chronic illnesses that are not well-controlled.
- Prompts that remind behavioral health providers to monitor basic physical health care vital signs and labs such as blood pressure, body mass index (BMI), fasting glucose, and, for those on psychotropic medications, kidney and liver functioning.
- Flags for high-risk patients that need outreach or follow-up.
- Prompts that guide clinical decisions and medication selection consistent with evidence-based care guidelines.
- Expanded Data Elements for Complex Patients: To effectively support the coordinated care of complex patients, a CIS needs the capacity to capture a broad range of data elements based on client needs. To generate informative, tailored, client-specific data displays, a CIS needs to consider additional information such as:
- Psychosocial and social determinants of health, and risk factors associated with family history, environment, and behaviors
- Care management encounters including enabling services like transportation, connection to housing, and food stamps
- Level of patient activation and person-centered goals.
- Individual health and wellness profile (e.g., nutrition, exercise, and stressors).
- Treatment Progress and Measurement: Providers need a means to facilitate treatment decisions and track patient and population health outcomes. CIS products are commonly designed to measure and track physical conditions and outcomes, but they often lack comparable capability for tracking mental health or substance use outcomes. Expanding measurement functionality to include categories such as depression and anxiety symptom severity, functional status and substance use is critical.
- Patient Engagement: A CIS needs to support the engagement of clients in their care management and self-care. CIS functionality supports patient engagement and promotes behavior change by providing a view over time of clients’ vital signs, lab results, and other measures (e.g., weight loss, smoking cessation, and chronic illness management). A CIS can also provide patient access to their health record to promote self-management and facilitate patient-provider communication and direct appointment scheduling.
- Proactive Care and Prevention: A CIS needs the capacity to support proactive care and prevention at both the individual patient and population levels. A CIS can identify patients that need outreach for age or gender-specific preventative services, and provide capacity to stratify and analyze high-risk patient populations, which in turn supports proactive, cost-effective care.
Data & Clinical Content
- Demographics: While patients’ demographics are routinely captured in CIS tools like registries, they are often missing information related to the social determinants to health. It is recommended this category be altered and expanded to include information such as financial security, employment and housing status, food security, neighborhood and household safety.
- Diagnoses/Conditions: As is the case with most patient registries, a CIS should contain all possible diagnoses and conditions. To support MH/SUD integration, a CIS should include all diagnoses in the DSM (ideally aligned with ICD codes).
- Medicines: To support the integration of MH/SUD concerns, the medication lists in CIS should include all psychotropics by specific medication as well as drug class. In addition, to support shared care planning and coordination, the name and contact information of prescribers should also be included.
- Lab and Other Diagnostic Tests: The category of labs and other diagnostic tests should be expanded and used to keep track of the results of tests ordered by all providers in the care team, including dates tests were ordered and completed to facilitate follow up. The availability of these data is vital to enabling routine treatment reconciliation and whole person care.
- Care Team: Names, contact information, and roles of all care team members need to be available in a CIS. Team members include other providers, the care coordinator or navigator, and key family member or other supports. For known providers who are care team members, these data can be pre-populated and available in pull-down menus. This approach would allow reporting and querying by team member names.
- Levels of Functioning: A patient’s level of functioning is critical to treatment and self-care and should inform all care planning and treatment. Elements to consider include, activities of daily living, instrumental activities of daily living, social supports and learning disorders.
- Risk Factors: Family risk factors such as family medical history, structure and dynamics, history of suicide, domestic violence, and child abuse are important to document given their impact on treatment effectiveness. Other risk factors to consider include, legal and criminal history, involvement with social service or correctional agency,and gun ownership and access.
- Patient Goals and Directives: To be person centered, it is important to capture the treatment goals and preferences in the words of the patient. This area can also include advanced directives.
- Consults, Education and Referrals: In terms of data-sharing, care coordination and outcome tracking, this category of data is one of the most important and must be expanded to include all types of services, including medical, behavioral, social service, self-help, educational, and benefits advocacy, and should include dates of referred services, roles and responsibilities for scheduling and follow-up, status of referrals and outcomes.
Implementation
- Leadership and Oversight: Strong leadership is essential to help behavioral health and primary care practices make the cultural shift to understanding the use of CIS systems for data sharing across organizations to improve care coordination. Factors that facilitate this include:
- Clear guidance on how and what data can be shared across systems (including State interpretation on HIPAA regulations to create data sharing standards across counties), and then development of appropriate data sharing policies and agreements.
- Consensus between primary care and behavioral health about a set of core data elements to be captured and shared.
- Organizational leaders or change “champions” to be the “go to” persons within their respective departments/units who have the comfort level and fluency with the technology to support the learning among others.
- Strong IT management leadership and skills to help bridge the “generation gap” with regard to use of technology.
- Clinical and Operational Processes: Implementing a CIS requires attention to how the system will be incorporated into everyday clinical practices and operations within the context of clinics, including operational work flows and workforce retraining to help clinicians use data for improvement.
- Cross-Sector Collaboration: To ensure that clinical information systems are designed to support the administration and delivery of integrated, coordinated care, leaders and clinicians from primary care and behavioral health need to work collaboratively to improve the functionality and flexibility of CIS to support person-centered care.
- Clarify HIPAA regulations across public systems to eliminate barriers and promote data sharing across primary care, mental health, and substance use systems and providers.
- Develop a standard template of essential data elements for integrated behavioral health that can be used by clinics, counties, and behavioral health contractors.
- Foster continued collaboration between clinics and county mental health recognizing that optimal care coordination across provider organizations requires business agreements, MOUs and opportunities for regular communication.
The information included here is from the California Healthcare Foundation report prepared by Manatt, Phelps & Phillips, LLP: Fine Print: Rules for Exchanging Behavioral Health Information in California.
A 2012 survey of behavioral health organizations found that although 65% of respondents are using an EHR in at least some of their sites, only 21% reported being “all electronic” and only 11% could use EHRs in a way that would enable them to meet federal EHR incentive program requirements (behavioral health providers are generally not eligible for the federal incentive program).
Although obstacles to the sharing of behavioral and physical health data for care coordination are not just about technology, participants in all three of the initiatives explored in this paper expressed frustration with the lack of interoperability between EHRs used by county mental health providers and EHRs used by physical health providers. Interoperability has been defined by the federal Office of the National Coordinator for Health IT (ONC) as “the ability of a system to exchange information with, and use information from, other systems without special effort on the part of the customer.”
Simply put, interoperability should enable easy sharing of behavioral and physical health data between disparate systems in such a way that new information received by a health care provider can be populated into its record system without additional manual processes or human intervention. The lack of interoperability among medical record systems purchased by health care providers participating in the federal “meaningful use” electronic health record incentive program is a major focus for ONC, and ONC has received public comments on a draft roadmap for achieving interoperability. Issues of interoperability are magnified for health care providers who, in some circumstances, must obtain patient authorization prior to disclosing health information to assure legal compliance and may need to both record that authorization and in some cases pass it along to the recipient provider to facilitate exchange.
The authorization requirements under Part 2, described above, pose a particular challenge for health information exchange, and California substance abuse treatment laws, which are similar to Part 2, apply to an even broader set of substance abuse treatment providers. As noted above, these laws require individual authorization for both the initial disclosure by the substance abuse treatment provider and any subsequent re-disclosure by the recipient physical health provider. Most physical health providers with electronic medical records today are using “certified electronic health record technology” as part of the federal incentive program; however, this technology currently is not required to have the capability to honor Part 2 re-disclosure requirements.
The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has been working with ONC to pilot technological approaches to achieving compliance with Part 2, both for substance abuse treatment providers and for physical health providers. The Data Segmentation for Privacy (DS4P) pilots have demonstrated the ability to exchange summary-of-care documents using the documentation standard — the Consolidated Clinical Document Architecture, or Consolidated CDA — required for the federal EHR incentive program. The DS4P standard, which has been adopted by HL7, the international health data standards body, enables substance abuse treatment providers covered by Part 2 to send standard care summary documents that are flagged (using metadata tagging) to indicate that the information is subject to Part 2 and may not be re-disclosed without further authorization from the patient.
This technology, when present also in the receiving provider’s electronic health record, enables that provider to view the information in the care summary document, but does not allow that document to be uploaded or “consumed” by the provider’s electronic health record because the information, once it is parsed from the document, could be inadvertently disclosed. Technology to enable the Part 2 “flag” to remain with the information, even after it has been accepted into another provider’s electronic health record, is not yet in widespread use.
This method of exchanging records does not achieve full interoperability; however, the federal Health IT Policy Committee, which is an advisory body to ONC, called it an important first step toward achieving interoperability for information covered by Part 2 and urged ONC to include the technology as part of its electronic health record certification program. ONC has recently issued a proposed EHR certification rule that would require the DS4P standard to be included in certified EHR technology. SAMHSA reports that some substance abuse treatment programs are using DS4P and other technologies to begin exchanging information with other providers.
For additional information, see the California Healthcare Foundation report prepared by Manatt, Phelps & Phillips, LLP: Fine Print: Rules for Exchanging Behavioral Health Information in California.