Certification / Adoption Workgroup

1. Certification / Adoption Workgroup Larry Wolf, chair Marc Probst, co-chair January 24, 2014 10:00 am ET

2. Agenda • Review of Agenda • HITPC Charge: Step Two • Background Regarding Behavioral Health (BH) Providers • Who are BH providers? • What is the clinical utility of EHRs to BH settings? • What is known about EHR adoption by BH providers? • 5 Factor Framework – Considerations related for BH • Next Steps • Virtual Hearing – ONC EHR Certification for BH, 01/28/14 • Public Comment

3. Call Schedule *Dates in red are changes from previous call schedule.

4. Presenters Maureen Boyle, HHS/SAMHSA Sue Mitchell, RTI International Mike Lardieri, National Council for Community Behavioral Health

5. SAMHSA’S STRATEGIC INITIATIVES 4 To reduce the impact of substance abuse and mental illness on America's communities

6. SAMHSA’s Strategic Initiative - Health IT • Goal: Widespread Implementation of HIT Systems that Support Quality Integrated Behavioral Health Care for All Americans • Ensure that behavioral health providers fully participate in the adoption and effective use of Health IT

7. Value of a Voluntary BH EHR Certification • Interoperability with broader healthcare system • Confidence in the vendor and in a base level of functionality • Promotion of data standards • Minimize data re-entry • Improve data quality for reporting • Support secondary uses such as research

8. Value of a Voluntary BH EHR Certification • Some providers are delaying adoption for fear that existing systems may become obsolete in this rapidly changing HIT environment. • Behavioral health providers often exist at a near subsistence level and would not recover from the loss of such a large capital investment. • SAMHSA would like to encourage BH providers to adopt EHRs that are interoperable with those being adopted by the broader healthcare system, without requiring BH providers or technology vendors to commit resources to develop functionality that is not required for their scope of practice. • A voluntary certification program would provide a mechanism for us to verify that the EHRs purchased using federal funds meet a core set of standards.

9. Behavioral Health Providers • Eligible providers: • Psychiatrists • Psychiatric nurse practitioners (only under Medicaid) • Ineligible providers:

10. Considerations for structure of a voluntary certification program for BH • Diverse provider types with diverse workflows • Prescribers- psychiatrists, psychiatric nurse practitioners • Therapy or counseling focused practice • Opioid treatment programs • Residential mental health or substance abuse programs • Social work- integration with social services, housing, criminal justice, etc. • Integrated care settings

11. Privacy and Confidentiality Requirement • 42 CFR Part 2:The purpose of the statute and 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

12. Privacy and Confidentiality Requirement • 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) with limited exceptions such as medical emergencies • Consent must include purpose of use • Prohibition on re-disclosure without consent

13. Other Federal and State Laws • 42 CFR Part 2 sets a minimum standard for protecting and security protected health information (PHI). If the state law is more restrictive then the state law governs. • 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 • Systems have to recognize this variability in state statutes and regulations. • HIPAA self-pay rule

14. Privacy and Confidentiality Requirement • Standards for communicating privacy policies and obligations • Developed through DS4P Initiative • Just balloted at HL7 • http://www.hl7.org/ballots/recirculation/info.cfm?recirc_id=783 • All EHRs need to be able to control the re-disclosure of protected information

15. Considerations for structure of a voluntary certification program for BH • Flexible program to meet the needs of diverse provider types • Modular (provider organizations can make recommendations related to which functional modules are core for specific provider types) • Or, a program focused on the needs that are core to all • Core BH functionality (core to all BH provider types) • Core for all healthcare providers (interoperability, privacy and security, etc.)

16. Example of Modular Certification Program B PRESCRIBING C ASSESSMENTS A INTEROPERABILITY SECURITY DEMOGRAPHICS • Psychologists- A, C, D, E • Psychiatrists- A, B, C, D, E, F • Housing and Urban Development- A, C D PATIENT COMMUNICATION E CLINICAL QUALITY MEASUREMENT F LABS AND IMAGING

17. History of efforts to develop a BH Certification • In early 2013 SAMHSA began working with ONC to develop sub-regulatory guidance to support a voluntary BH certification program • Based on core Meaningful Use certification criteria that apply across all behavioral health provider types

18. Elements of a BH Core • Criteria from MU2 • Interoperability • Documentation • Integration of care • Privacy and Security • Healthcare quality improvement • Patient communication • Software Quality Assurance

19. Core MU2 criteria for BH

20. MU Criteria not core to BH • Criteria were excluded that support functions that are not core for a majority of ineligible behavioral health providers. These include core functions and associated criteria: • Prescribing: The majority of ineligible behavioral health providers do not have prescribing authority therefore these criteria were not included: • Computerized provider order entry § 170.314(a)(1) • Drug-drug, drug-allergy interaction checks § 170.314(a)(2) • Drug-formulary checks § 170.314(a)(10) • Electronic medication administration record (eMAR) § 170.314(a)(16) • Electronic prescribing § 170.314(b)(3) • Safety-enhanced design § 170.314(g)(3) • Labs and imaging: Ineligible BH providers typically do not rely on labs test or radiology. There are ineligible BH providers who capture lab tests for urinalysis and other purposes however we are focused on the core set that apply to the vast majority of ineligibles. • Image results § 170.314(a)(12) • Incorporate lab tests & values/results § 170.314(b)(5) • Transmission of electronic lab tests & values/results to ambulatory providers § 170.314(b)(6) • Transmission of reportable lab tests & values/results §170.314(f)(4

21. MU Criteria not core to BH • Collecting vital signs • Vital signs, BMI, & growth charts § 170.314(a)(4) • Reporting to immune and cancer registries • Immunization information § 170.314(f)(1) • Transmission to immunization registries § 170.314(f)(2) • Cancer case information § 170.314(f)(5) • Transmission to cancer registries § 170.314(f)(6) • Syndromic surveillance • Transmission to public health agencies – syndromic surveillance § 170.314(f)(3) • Implementing advanced directives • Advance directives § 170.314(a)(17) • Other criteria were excluded that support functionality specific to the Meaningful Use EHR program including: • Reporting to CMS • Clinical quality measures § 170.314(c)(3) • Calculation of MU objectives • Automated measure calculation § 170.314(g)(2)

22. HIT/EHR Adoption Rates for Behavioral Health Providers HIT/HER Adoption Rates

23. Patients Served by Ineligible Providers/Hospitals • Inpatient Psychiatric Hospital including substance abuse: 1,909,238; • Residential Treatment Centers including subtance abuse: 314,393; • Clinical Psychologist/Social Worker: 9,929,900; • Community Mental Health Clinic: 6,000,000 • Total: 18,152,631

24. Behavioral Health Provider Use of EHRs in Practice From Other Provider Study: • Significant variability across provider types

25. HIT Adoption in Community BH • In 2012 the National Council for Community Behavioral Healthcare conducted a survey of HIT Adoption and Meaningful Use Readiness in Community Behavioral Health settings • Survey was completed by more than 500 community mental health and addictions treatment organizations

26. HIT Adoption in Community BH

27. HIT Adoption in Community BH

28. 5 Factor Framework When evaluating whether to establish a new certification program, ONC should consider whether the proposed certification program would:

29. Factor #1 • National Quality Strategy • National Behavioral Health Quality Framework • Health Reform • Integration of care • Shared savings programs

30. NBHQF and NQS • 3 Aims: Better Care, Healthy People/Healthy Communities, Affordable Care. • 6 Priorities – • Evidence-based practices • Person-centered care • Coordinated care • Healthy living for communities • Reduction of adverse event • Cost reductions

31. Prevalence of BH Disorders http://www.samhsa.gov/data/2012BehavioralHealthUS/2012-BHUS.pdf

32. Need for HIE in Behavioral Health • On average, Americans with major mental illness die 14 to 32 years earlier than the general population. • Average life expectancy ranged from 49 to 60 years of age in the states they examined compared to 77.9 years for the general population • Due to physical health problems— cancer, heart disease, stroke, pulmonary disease, and diabetes • More likely to suffer chronic diseases associated with addiction (especially nicotine), obesity, and poverty • People with a mental illness are more than twice as likely to smoke cigarettes and more than 50 percent more likely to be obese compared to the rest of the population • Study suggested that implementing a collaborative care approach for depression in the Medicare system would result in cost savings of approximately $15 billion annually.

33. Co-morbidities of Chronic Conditions National Comorbidity Survey Replication, 2001-2003 as Reported in Druss and Walker, 2011

34. Exhibit 7 http://www.chcs.org/publications3960/publications_show.htm?doc_id=1058416

35. Costs Associated with Comorbid Chronic Physical and Behavioral Health Disorders Center for Health Care Strategies, Inc., Dec 2010, www.chcs.org/usr_doc/clarifying_multimorbidity_patterns.pdf

36. Figure 3.3 http://www.samhsa.gov/data/2012BehavioralHealthUS/2012-BHUS.pdf

37. 30-Day Readmissions by Major Diagnostic Category (MDC) Medicaid recipients Age 21-64, 2007 Among 15 states, behavioral health discharges ranked among the top 5 diagnostic categories for 30-day readmissions. Agency for Healthcare Research and Quality (AHRQ) Health Care Utilization Project Statistical Brief #89, 2010

38. Potentially Preventable ReadmissionsNew York State Medicaid Program, 2007

39. Need for HIE in Behavioral Health • Multiple studies have shown that readmission rates can be reduced with care coordination

40. Prevalence of BH Conditions among MedicaidExpansion Population CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

41. Prevalence of BH Conditions among Exchange Population CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

42. Potential Benefits of HIT/HIE in Behavioral Health Settings • Efficiencies • Patient safety • Patient and family engagement • Data analytics (e.g., population management, resource requirements, etc.) • Quality, coordination, and cost improvements • Data re-use • Competitive in marketplace

43. Factor 1 Conclusions • Use of CEHRT by BH providers has the potential to improve HIE, improve quality, continuity, and coordination of care, and enhance safety in BH settings. • HIT is a critical tool to support many elements of health reform and new service delivery models . • Success will depend on: • Adopting criteria that supports critical functionality • Alignment with existing health IT standards • Extent of use within BH EHR products • BH provider acquisition and use of certified products that supports the needed functionality

44. Factor #2 • Standardized screening and assessment tools • Foundation for using the EHR transport standards for federal and state reporting • Quality measurement program standards

45. Behavioral Health – Federal and State Mandated Assessments • Assessments support multiple purposes: screening, assessment and care planning, outcome tracking, payment, quality monitoring/reporting, and/or survey and certification activities. • Generally, data elements, while similar, are not equivalent across instruments • State reporting- Each state has specific reporting requirements • E.g. Child and adolescent functional assessment scale (CAFAS) in Michigan, Alaska Screening Tool (AST); Client Status Review (CSR) in Alaska • Also county specific requirements

46. Behavioral Health – Federal and State Mandated Assessments • HL7 Implementation Guide for CDA : Patient Assessments • http://www.hl7.org/implement/standards/product_brief.cfm?product_id=21 • Foundation for using the EHR transport standards for federal and state reporting • SAMHSA grants • CMS • HUD • CJ

47. Quality and Performance Measure Reporting • Quality measurement programs • Inpatient Psychiatric Facility Quality Reporting (IPFQR) • The Joint Commission’s Hospital-Based Inpatient Psychiatric Services (HBIPS) • The Joint Commission’s Substance Abuse Measure set • ACO Data Reporting Requirements • SAMHSA government performance reporting (GPRA) • State Medicaid reporting • Push to use of electronic quality and performance measures • Reduce re-entry • Improve quality of data

48. Programs Supporting HIT/HIE Behavioral Health New service delivery models • ACOs • Bundled payment models • Balancing Incentive Programs (LTSS & HCBS) • Medicaid Health Home State Plan Option (Patient-Centered Medical Homes (PCMHs) • Community-Based Care Transitions Program • State Innovations Models (SIMs) • SAMHSA/HRSA PBHCI • Hospital Readmission Reduction Program • Parity • Medicaid expansion (% with BH disorders) • Medicare Physician Fee Schedule Enhancements

49. ONC Certification & Alignment with BH QM Requirements • ONC Certification program will not (on its own) address/resolve: • The lack of policy alignment between CMS and ONC submission/transmission requirements • The lack of alignment in reporting requirements between federal and state programs • The proliferation of non-aligned QMs across the care continuum

50. Factor 2 Conclusions • Identification and inclusion of key EHR certification criteria and functions in a voluntary BH EHR certification program could provide a foundation for alignment of Federal/State Programs • Implementation of a voluntary EHR certification program in BH could create efficiency gains, permit re-use of data, and enable/support quality improvement and care coordination activities/efforts at Federal, State, and provider levels