TCE-HIT Grantee Meeting Rockville, MD  September 7, 2012

Advancing Technology-Assisted Care in Behavioral Health H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Behavioral Health Statistics and Quality Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services TCE-HIT Grantee Meeting Rockville, MD  September 7, 2012

President’s Vision for Health IT • Medical information will follow consumers so that they are at the center of their own care • Consumers will be able to choose physicians and hospitals based on clinical performance results made available to them • Clinicians will have a patient's complete medical history, computerized ordering systems, and electronic reminders. President Barack Obama

“The increased use of health information technology is a key focus of our reform efforts because it will help to improve the safety and quality of health care generally while also cutting waste out of the system.” Kathleen Sebelius Secretary U.S. Department of Health & Human Services September 29, 2009

SAMHSA: Key Messages • Behavioral health is essential to health • Prevention works • Treatment is effective • People recover from mental and substance use disorders Pamela S. Hyde, J.D.Administrator Substance Abuse and Mental Health Administration

Challenges • In 2010, an estimated 22.1 million persons were classified with substance abuse or dependence. • 2.9 million of them were dependent upon or abused both alcohol and illicit drugs. • And, during 2009, there were an estimated 11 million adults (18 or older) in the U.S. – 4.8% of adults -- with serious mental illness in the past year. Source: 2009 & 2010 NSDUH

Substance & Alcohol Dependence/Abuse & Treatment • In 2010, an estimated 22.1 million persons aged 12 or older were classified with substance dependence or abuse in the past year (8.7 percent of the population aged 12 or older) • Of these, 2.9 million were classified with dependence or abuse of both alcohol and illicit drugs. • 4.1 million persons aged 12 or older (1.6 percent of the population) received treatment for a problem related to the use of alcohol or illicit drugs in 2010. Source: 2010 NSDUH, p. 69 & 76

Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2010 20.5 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use Source: NSDUH 2010

Reasons for Not Receiving Substance Use Treatment: For those who Needed & Made the Effort to Get Treatment But Didn’t Receive It - Aged 12+ Percent Reporting Reason Source: NSDUH, 2006-2010 combined

Why Health IT? • Broad use of Health Information Technology has the potential to: • improve health care quality, • prevent medical errors, • increase the efficiency of care provision and reduce unnecessary health care costs, • increase administrative efficiencies, • decrease paperwork, • expand access to affordable care, and • improve population health. Sources: www.healthIT.hhs.gov and USDHHS (01 October, 2009) A Success Story in American Health Care Retrieved from www.healthreform.gov

Why Health IT? (cont’d) • Health IT can significantly increase access to treatment for rural and other underserved communities that are often isolated and lack access to comprehensive, high-quality health care. • Effective use of health IT can increase access for those with special needs, such as deaf clients or those with limited mobility. • Health IT encourages patients to become more actively involved in their treatment. Sources: www.healthIT.hhs.gov and USDHHS (01 October, 2009) A Success Story in American Health Care Retrieved from www.healthreform.gov

Why HIT? (cont’d) CDC, (2010) Health Information Technology Use Among U.S. Adults, Retrieved from http://www.cdc.gov/Features/dsHealthInfo/

Why Hit? (cont’d) CDC, (2010) Health Information Technology Use Among U.S. Adults, Retrieved from http://www.cdc.gov/Features/dsHealthInfo/

Technology-Assisted Treatment • Technology-assisted treatments allow for “tailored health interventions” – an individualized response resulting from gathering and appraising information from the individual. • Tailored health interventions have been shown to be effective in engaging individuals and improving their healthy behavior.

Using HIT to Reduce Waste • One of the goals of Health IT is to reduce waste within programs by reducing redundancy and improving quality of care. • Interoperable electronic health records provide information that can be shared among multiple participants in an episode of care, including providers, patients, and family caregivers. • Result: improved communication, clearer understanding, and a more integrated and patient-centered treatment.

Using HIT to Better Engage Patients in Care • Health IT increases patient involvement by creating an opportunity to better engage individuals in their care through use of technology which will, in turn, improve health outcomes. • The functionality of interoperable EHR systems can connect patients to community resources and supports, provide information that permits them to participate in shared decision-making with their clinicians, and support home monitoring of reported symptoms related to chronic conditions with the goal of preventing unnecessary hospitalization.

Grantee Success: Engaging Patients Grantees have seen the positive impact that an effective use of technology can have on treatment. • Last Memorial Day activities led to a Drug Court client, who is also a vet, relapsing. However, he used his Smart Phone application to reach out for help. • The Drug Court’s Peer Support staff were able to transport him to the local VA, where he was able to receive treatment. • From Advocates, Inc., Framingham, MA

Grantee Success: Increasing Access • A deaf client with a history of unsuccessful treatment due to the lack of an interpreter and his rural location, also struggled with isolation. • After enrolling in Project CAN, he is now actively engaged in his weekly classes and is supporting others through the ACHESS Smart Phone app. • From Arapahoe House, Inc., Thornton, CO

Grantee Success: Patient-centered • A mother of two teenage daughters, who works 60+ hours a week, had been a heavy drinker for years. • She was drawn to the grantee’s technology-assisted program because “she couldn’t put her life on hold” to get treatment. • By using the provider’s website with self-help materials and a second website (TES) that provides computer-based skills training for relapse prevention, the client can access treatment and support and fit them into her demanding schedule and lifestyle. • She has now celebrated 2 months of sobriety. • From Human Service Center, Peoria, IL

Grantee Successes (cont’d.) Other grantees are using technology to expand their access and enhance services, including: • Text message reminders to clients – reducing the number of reschedules, cancellations and, particularly, no-shows. • Video conferencing equipment improves access to rural communities. • Daily cell phone text message program that uses motivational interviewing. • Client portal that allows individuals to view assessment data, view/add and comment on treatment-related tasks, send confidential messages to counselors, and keep contact information up to date. (Via Smart Phone, tablet, desk top, wherever Internet is available.)

Using Health IT Performance Measures • Health IT performance measures will 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? • How do we demonstrate success?

Success: Using HIT to Measure & Report For example: • An in-house GPRA tracking system allows the grantee to continually monitor intakes. • The grantee also created an internal census/tracker report and an internal outcome report. • The tools provide data to monitor performance in meeting the grantee’s goals and objectives. • Northern Ohio Recovery Assn., Cleveland, OH

Ensuring Confidentiality and Trust • Increased accessibility to health records raises the question of how to ensure patient confidentiality and trust. • In order to achieve any level of systemic durability and success, electronic exchange efforts must establish trusting relationships with all participants, including patients. (Melissa M. Goldstein, JD et al, 2010)

The Impact 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. Source: State of Florida Center for Drug-Free Living , Inc.,842 So.2d 177 (2003) at 181.

The Role of States • 42 CFR Part 2 set a minimum standard for protecting and security protected health information (PHI). If the state law is more restrictive then the state law governs. • For example, mandatory child abuse reporting laws in each state are unaffected by 42 CFR Part 2. • A local, county, or state counsel can advise whether state law of federal law is more restrictive in a given area.

Critical Health IT Questions • 42 CFR Part 2 and other regulations provide the ground rules, but how those rules are applied to ensure effective treatment of substance use and mental health disorders needs to be determined through careful analysis. • Who needs what information when? • Who determines who needs what Information when? • How should psychotherapy notes be treated – as part of the patient record?

Principles of Fair Information Practices • Individual Access • Correction • Openness and Transparency • Individual Choice • Collection, Use, and Disclosure Limitation • Data Quality and Integrity • Safeguards • Accountability

SAMHSA’s HIT Objectives • Increase the involvement of behavioral health organizations in state Health information Exchange (HIE) pilot activities • Increase the number of behavioral health organizations meeting meaningful use activities • Address the issues of privacy and security associated with mental illness and substance use disorder treatment • Develop working relationship with Medicaid, Mental Health and Substance Use Authorities

Meaningful Use • To qualify for incentives, eligible providers must demonstrate “Meaningful Use”: • The use of a certified EHR in a meaningful manner, such as e-prescribing. • The use of certified EHR technology for electronic exchange of health information to improve quality of health care. • The use of certified EHR technology to submit clinical quality and other measures. Source: https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp#BOOKMARK1

SAMHSA Strategic Initiative - Health Information Technology • Purpose: Ensure 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. • Primary role of SAMHSA’s HIT effort is to support the behavioral health aspects of the electronic health record based on the standards and systems promoted by the Office of the National Coordinator for Health IT.

SAMHSA Health IT Strategic Initiative Goals • Develop the infrastructure for interoperable Electronic Health Records, including privacy, confidentiality, and data standards. • Provide incentives and create tools to facilitate the adoption of Health IT and EHRs with behavioral health functionality in general and specialty healthcare settings. • Deliver technical assistance to State Health IT leaders, behavioral health and health providers, patients/consumers, and others to increase adoption of EHRs and Health IT with behavioral health functionality. • Enhance capacity for the exchange and analysis of EHR data to assess quality of care and improve patient outcomes.

HIT Activities: Meetings • SAMHSA held three HIT Regional Forums: • Participants were from 50 states and U.S. territories. • Objective: to 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.) • SAMHSA is also meeting with behavioral health software vendors, including Netsmart and SATVA.

Challenges Grantees also report challenges, including: • The slow speed in which the State’s HIE is being created. • Limited interoperability and coordination. • Recruitment of program participants • Lack of technology marketing strategy • Difficulty connecting with the criminal justice system, primary health care, faith-based groups, etc. to expand reach and access. • Working with diverse organizations to create a cohesive network.

SAMHSA Behavioral Health Exchange Initiative with 5 States • Coordinated through the National Council for Community Behavioral Healthcare (NCCBH). • One year initiative with: Maine, Illinois, Kentucky, Oklahoma, and Rhode Island. • These five HIEs will disseminate their work and lessons learned as part of the project to benefit the HIE’s nationally. • The development and implementation timeframes for other HIEs will be dramatically shortened due to the lessons learned from the 5 states.

SAMHSA Behavioral Health Exchange Initiative with 5 States (cont’d.) • Each state has initiated a statewide meeting with their behavioral health providers to identify the benefits for BH providers in the state and solicit their input. • KY, IL and ME now have behavioral health workgroups. • A baseline has been established for each state re. the number of BH providers currently in the HIE. • This will be tracked over time to follow the progress of BH involvement in the HIE.

SAMHSA Behavioral Health Exchange Initiative with 5 States (cont’d.) • Regarding 42 CFR Part 2: • States are working through issues of 42 CFR compliant consents to identify barriers and recommend needed solutions for success with HIEs. • States are also focused on BH information in the Continuity of Care Document (CCD) regarding • what is currently included, • what additional data elements are needed to improve coordination and quality of care when a BH provider receives information from other providers.

Addiction Comprehensive Health Enhancement Support System (A-Chess) • SAMHSA is testing the Addiction Comprehensive Health Enhancement support System (A-Chess) – a Smartphone-based recovery tool that that features: • Online peer support group & clinical counselors, • A GPS feature that sends an alert when the user is near an area of previous drug or alcohol activity, • Real-time video counseling, and • A “panic button” that allows the user to place an immediate call for help with cravings or triggers.

SAMHSA HIT Standards Development • Open Behavioral Health Information Technology Architecture (OBHITA) project: • SAMHSA is 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), and • With the ONC Standards and Interoperability Framework for Data Segmentation for Privacy (DS4P) to identify exchange standards for patient consent information across EHRs.

SAMHSA HIT Collaborations • Collaboration with Centers for Medicare and Medicaid Services re. preparation for the conversion to ICD-10 • SAMHSA is working with CMS to identify and track SAMHSA and its grantees re. preparation for the transition to ICD-10 diagnostic and procedures billing codes. • ICD-10 transition date: 10/1/2013 • Collaboration with Department of Army • Purpose: to extend the content and functionality of an existing Dept. of Army project to incorporate SAMHSA substance abuse and mental health facility electronic records and related crisis centers into the existing Geographic Information System (GIS).

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). • Both documents are developed by the Legal Action Center. • These FAQs and other information regarding privacy can be accessed at: http://www.samhsa.gov/healthprivacy/ 40

Health Information Technology Goes Beyond EHR • Beyond the increased emphasis on interoperable EHR systems, the behavioral health field needs to be ready for the sweeping changes that technology brings: • The ability to identify new substances and exploit existing ones to trigger a euphoric or psychedelic effect (salvia, K2, bath salts) • The effect of social networking to get the message out, exchange information, build a community of users. • The ability to connect with suppliers throughout the world, who promise anonymous or discreet packaging and accept cash transfers.

Using Technology Effectively • Continue to investigate the opportunities presented by social media – Facebook, YouTube, Twitter, etc. • View technology tools as an integrated network – many people own Smartphones, I-pads, tablets, GPS systems – design tools that integrate the individual tools. • Encourage the development of outreach tools that exploit emerging technology.

Mobile Applications • Health apps are considered to be programs that offer health-related services for smart phones and tablet- PCs. They can also be internet based-tools that are accessible from a PC. Apps can be used for self-monitoring purposes or in collaboration with treatment providers • More providers in many areas of medical practice are beginning to encourage the use of health apps for assistance in treating conditions and promoting general wellness • The desired goal of apps is to increase participation in one’s own health care, increase access to information and create linkage to care

Effective Use of Social Media • Fundraising and Social Awareness campaigns gain large audiences through outlets such as Twitter and Facebook  Social Media can be e used as a low-cost marketing and advertising strategy to promote services and attract clientele

Conclusion • Health IT has the capacity to change the behavioral health care field. • That impact will be felt by behavioral health providers, regardless of how fully they fit into the new system. • TCE-HIT grantees are in a position to lead the effort to use Health IT to create interoperable systems that increase access and provide patient-centered treatment that meets the needs of diverse and hard to reach populations.

THANK YOU.

TCE-HIT Grantee Meeting Rockville, MD  September 7, 2012