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SAMHSA Health Information Technology Initiative


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Title: SAMHSA Health Information Technology Initiative

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Welcome to Confidentiality, Substance Use
Treatment, and Health Information Technology
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Four-Part Webinar Series on
  • Confidentiality, Substance Use Treatment, and
    Health Information Technology (HIT)
  • First 3 Webinars Presented by the Legal Action
  • 4th Webinar Presented by SAMHSA

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SAMHSAs Vision for Advancing Behavioral
Healthcare throughHealth Information Technology
  • Maureen Boyle, PhD
  • Lead Public Health Advisor, Health Information
  • Center for Substance Abuse Treatment
  • Substance Abuse and Mental Health Services
  • May 25, 2012

Presidents 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.

  • 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
SAMHSAs Strategic Initiative - Health IT
  • Goal Widespread Implementation of HIT Systems
    that Support High Quality Integrated Behavioral
    Health Care for All Americans
  • Ensure the behavioral health provider networks
    fully participate in the adoption of Health IT
  • Working closely with the Office of the National
    Coordinator for Health IT to support inclusion of
    behavioral health

National HIT Landscape
  • The Health Information Technology for Economic
    and Clinical Health Act ( HITECH Act)
  • Meaningful Use, EHR Certification
  • Large national investment in HIT
  • Largely excludes behavioral health providers
  • The Affordable Care Act
  • Privacy and Confidentiality Regulations
  • 42 CFR Part 2
  • State laws

Health Information Exchange
  • CMS and ONC define the requirements for
    meaningful use and certification of EHRs
  • Large national investment in HIT
  • Largely excludes behavioral health providers
  • Funding for Regional Extension Centers and Health
    Information Exchange Networks
  • NPRMs for Stage 2 were released on March 7th and
    the final rule is expected by the end of the
  • Multiple items of relevance to behavioral health
  • Clinical Quality Measures
  • Privacy and Confidentiality

Meaningful Use
Stage 2
Meaningful Use Incentive Program
Useful Links
  • CMS https//
  • ONC http//
  • Certified EHR http//
  • Regional Extension Centers
  • http//

The Affordable Care Act
  • Establishing patient-centered medical homes
    (PCMH) and accountable care organizations (ACO)
  • Focus on coordinating care and pay for
  • Formation of an ACO is contingent upon HIT for
    information exchange and quality measure

Privacy and HIT
  • Privacy and Confidentiality Regulations
  • 42 CFR Part 2
  • State specific laws

Ensuring Confidentiality and Trust
  • Increased accessibility to health records raises
    the question of how to ensure patient
    confidentiality and trust.
  • To be sustainable, electronic exchange efforts
    must establish trusting relationships with all
    participants, including patients.

Melissa M. Goldstein, JD et al, 2010
42 CFR Part 2
  • Patient consent must be obtained before sharing
    information from a substance abuse treatment
    facility that is subject to 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.

Source State of Florida Center for Drug-Free
Living , Inc.,842 So.2d 177 (2003) at 181.
42 CFR Part 2
  • Patient consent must be obtained before sharing
    information from a substance abuse treatment
    facility that is subject to 42 CFR Part 2
  • Prohibition on re-disclosure without consent
  • Limited exceptions for disclosure without consent
  • Medical emergencies
  • Child abuse reporting
  • Crimes on program premises or against program
  • 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

Source 42 CFR Part 2
  • Non-Substance Use Disorder mental health records
    may be treated as ultra-sensitive in many
  • Each state approaches the confidentiality of
    mental health records from their own perspective
  • There are differences
  • There are similarities
  • EHR systems have to recognize this variability in
    state statutes and regulations.

Critical Health IT Questions
  • 42 CFR Part 2 and other regulations provide the
    ground rules. Careful analysis determines how the
    rules are applied to ensure effective treatment
    of substance use and mental health disorders.
  • Who needs what information when?
  • Who determines who needs what Information when?
  • How should psychotherapy notes be treated as
    part of the patient record?
  • How should HIT systems be designed to control
    disclosure and re-disclosure of sensitive

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
  • These FAQs can be accessed at http//www.samhsa.g
    ov/healthprivacy/docs/EHR-FAQs.pdf and
  • http//

The Health IT Challenge
  • Health IT will provide powerful tool to address
    the quality of care
  • The challenge is to be ready to use those tools
  • Only a small percentage of behavioral health
    providers have adopted interoperable Health IT
  • Even if the systems are in place, many do not
    have the personnel trained to effectively use

SAMHSAs Strategic Initiative - Health IT
  • The SAMHSA is working to advance Behavioral
    Health through Health IT
  • Technologies/policies for privacy and
  • Develop and test advanced functionality for
    Behavioral Health
  • Data segmentation and consent management
  • Behavioral Health Clinical decision support
  • Patient engagement and self-management
  • Development of data standards to ensure that
    information can be efficiently and effectively
    exchanged and interpreted
  • Behavioral health clinical quality measurement
  • Deliver technical assistance to increase adoption
    of HIT by the behavioral health community

Solutions for Privacy
Solutions for Privacy
  • Working to identify interim solutions for
    electronic exchange of health information that is
    subject to 42CFR Part 2 using existing technology
  • Working with technology and legal experts
  • Working with the ONC Standards and
    Interoperability Framework and the VA to develop
    open source technology for consent management and
    data segmentation to give the patient dynamic
    control over what information is shared

Data Standards
Benefits of Data Standards
  • The integration of behavioral health and physical
    health is contingent upon health information
  • It is critical that health care providers can
    interpret the information they receive from other
  • Standards for collection and storage of health
    information are needed for both interpretability
    and integration of data into the receiving record

Benefits of Data Standards
  • The adoption of interoperable data standards can
    improve patient care and facilitate research
  • More accurate and consistent data will be
  • Quality measurement
  • Real time outcome tracking and surveillance
  • Standard information will allow programs to cross
    reference and validate patient information.

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

Quality measurement
Quality Measurement
  • Quality measures have the potential to drive
    improvement in the healthcare system and can be
    used to demonstrate successful outcomes and
    reduced waste.
  • HIT performance and outcome measures will help
    answer the questions
  • Are our goals measurable and evidence-based?
  • Are we reaching the right populations?
  • Are client and treatment properly aligned?
  • Are our programs successful?

Quality Measurement
  • Structural Measures
  • Healthcare facility's organization and resources,
    such as nursing staff levels, or the presence of
    a behavioral health provider on a care team
  • Process Measures
  • The actual techniques used to treat patients,
    such as screening and brief intervention for
    alcohol use or depression
  • Outcome Measures
  • The consequences of a patient's interaction with
    the healthcare system (i.e. Did the patients
    depression score decrease with treatment)

SAMHSA Quality Measurement Activities
  • Developing clinical quality measures for
    behavioral health that are relevant for the
    meaningful use program

NQF 0109, Bipolar Disorder and Major Depression Assessment for Manic or Hypomanic Behaviors
NQF 0110, Bipolar Disorder and Major Depression Appraisal for Alcohol or Chemical Substance Use
NQF 0111, Bipolar Disorder Appraisal for Risk of Suicide
NQF 1385, Developmental Screening Using a Parent Completed Screening Tool (Parent report, Children 0-5)
NQF 0576, Follow-Up After Hospitalization for Mental Illness
NQF 1401, Maternal Depression Screening
NQF 1406, Risky Behavior Assessment or Counseling by Age 13
NQF 1507, Risky Behavior Assessment or Counseling by Age 18
NQF 0580, Bipolar Anti-manic Agent
NQF 1661, SUB-1 Alcohol Use Screening
NQF 1663, SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB-2a Alcohol Use Brief Intervention
SAMHSA Quality Measurement Activities
  • Two contracts are working with technical and
    clinical experts to determine what additional
    quality measures need to be developed to support
    behavioral health care
  • Both in primary and specialty care
  • New quality measures will be developed to fill
    gaps that are identified through this process

BH Treatment Lifecycle
BH Treatment Lifecycle
  • EHRs or PHRs can be used to
  • Collect patient reported information
  • Alert healthcare providers of patients at risk
  • Educate patient and link them to resources
  • Positive reinforcement

BH Treatment Lifecycle
  • EHRs/PHRs can collect patient reported standard
  • Computer adaptive testing to minimize burden
  • Automated Scoring to determine the level of risk
  • Alerts and reminders
  • To rule out alternative diagnoses
  • To assess contributing physical health problems
  • To alert provider to critical risks (i.e.
  • Collect standard data on patient symptoms

BH Treatment Lifecycle
  • Checklists for evidence based care
  • Links to clinical guidelines and information
  • Sharing information with patients
  • Linking patients to community resources
  • Consent Management for health information
  • Health Information Exchange tools
  • Referral appointment scheduling
  • Referral management and follow up tools
  • Care coordination tools

BH Treatment Lifecycle
  • Decision support for level of care
  • Treatment plan is auto-populated and modified by
  • Methods for capturing standardized data on
    non-pharmacologic treatments will be needed

BH Treatment Lifecycle
  • Evidence based practice checklists
  • Links to clinical guidelines
  • Alerts to identify patients who are falling
    through the cracks
  • If critical prescriptions are not refilled
  • If appointments are missed
  • Patient progress monitoring
  • Clinical decision support for adjusting
  • Step up to the next level of care
  • Continue in current care level
  • Enroll in recovery maintenance services
  • Data standardization to ensure interpretability
    across providers
  • Care coordination and management tools

BH Treatment Lifecycle
  • Structure, Process and Outcome measurement
  • Individual and community based results
  • Determine if evidence based protocols were used
  • Assess the efficacy of individual providers and
    healthcare systems
  • Public health reporting
  • Research to improve health service delivery

Learning Systems
  • Data can be analyzed to correlate symptom
    profiles and treatments used with Outcomes
  • Algorithm that determine the treatment plan can
    be updated based on feedback loop
  • Creates continuous learning environment
  • Personalized medicine
  • Support research into the biological basis of
    behavioral health disorders

Patient Engagement
  • Capturing patient reported data in the EHR
  • Interface with the patient through a web portal
    or PHR
  • Provide the patient with health information
    tailored to their own risks and to level of
    health literacy
  • Provide community and online resources
  • Tools to support shared decision making
  • Goal setting and tracking
  • Link with mHealth tools

SAMHSA HIT Activities Patient Engagement
  • Mobile Health Tools
  • Telephone Monitoring and Adaptive Counseling
    program, part of Access to Recovery
  • Life Wire A text messaging platform that
    supports ongoing client contact a continuously
    updating database that can be used to evaluate
    service effectiveness make program changes to
    support improved outcomes.
  • Addiction Comprehensive Health Enhancement
    Support System (A-Chess)
  • Features online peer support groups and 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 Activities Expansion Grants
  • SAMHSA awarded 29 Targeted Capacity Expansion
    (TCE)-Health IT grants.
  • To leverage technology to enhance or expand the
    capacity of substance abuse treatment providers
    to serve persons in treatment who have been
  • Examples include Web-based services, smartphones,
    and behavioral health electronic applications

SAMHSA HIT Activities Expansion Grants
  • SAMHSA has awarded 49 supplemental funds grants
    for Health IT infrastructure for current primary
    and behavioral health care integration (PBHCI)
  • To develop infrastructure that supports the
    exchange of health information through EHR data
  • Sub-awards support sharing of health records
    among behavioral health providers and general
    medical providers through a state HIE (ME, KY,
    IL, OK, RI)
  • Technological infrastructure
  • Privacy and Security Policies

  • Health IT has the potential to benefit behavioral
    health treatment providers and their clients
    through increased efficiency, coordination, and
    patient engagement.
  • 42 CFR Part 2 provides the ability to share
    protected health information, but it is the
    responsibility of the organizations to use that
    information in a way that benefits the health of
    the individuals.
  • SAMHSA is working to ensure that providers
    understand the benefits of integrating Health IT
    into their programs and that they have the
    training and tools to support their HIT goals.

  • Now for your questions...

Office of the Chief Privacy Officer (OCPO)ONC
Efforts to Maintain the Privacy of Health
Information Protected by 42 CFR Part 2
May 25, 2012 Scott Weinstein, JD
OCPO Overview
  • Chief Privacy Officer position created in HITECH
  • OCPOs responsibilities include
  • Advise the National Coordinator on privacy,
    security, and data stewardship of electronic
    health information
  • Coordinate with other Federal agencies, State and
    regional efforts, and foreign countries with
    regard to the privacy, security, and data
    stewardship of electronic individually
    identifiable health information

SAMHSA, ONC-OCPO, and 42 CFR Part 2
  • Enforces Part 2
  • Provides Guidance to Providers on Part 2
  • Working with SAMHSA to explore technologies that
    allow exchange of electronic substance abuse
    clinical information while complying with Part 2

ONC initiatives that implicate 42 CFR Part 2
  • Data Segmentation for Privacy
  • Query Health
  • SHPC Behavioral Health Data Exchange Consortium
  • State HIE Community of Practice Privacy and
    Security Workgroup on 42 CFR Part 2

Data Segmentation for Privacy Initiative
Data Segmentation for Privacy Objective
  • Produce a pilot project that will allow providers
    to share portions of an electronic health record
    while not sharing others
  • Certain privacy laws, such as 42 CFR Part 2,
    already require providers to ensure that parts of
    a medical record will not be shared without
    patient consent
  • Data Segmentation for Privacy provides a means
    for electronically implementing choices made by
    patients under these laws
  • Several use cases developed that focus on 42 CFR
    Part 2

User Story Example (1)
? The Patient receives care at their local
hospital for a variety of conditions, including
substance abuse as part of an Alcohol/Drug Abuse
Treatment Program (ADATP). ? Data requiring
additional protection and consent directive are
captured and recorded in the EHR system. The
patient is advised that the protected information
will not be shared without their consent.
User Story Example (2)
? A clinical workflow event triggers additional
data to be sent to Provider/Organization 2. This
disclosure has been authorized by the patient, so
the data requiring heightened protection is sent
along with a prohibition on redisclosure. ?
Provider/ Organization 2 electronically receives
and incorporates patient additionally protected
data, data annotations, and prohibition on
User Story Example (3)
? The Patient receives care for new, unrelated
condition and is referred by Organization 1 to a
specialist (Provider/Organization 3).
Organization 1 checks the consent directive and
sends authorized data to Organization 3. ?
Provider/Organization 3 electronically receives
and incorporates data which does not require
heightened protection.
Segmentation of medical information
  • Determine information covered by Part 2
  • Use standardized terminology to express that data
    came from a covered provider (FacilityType)
  • Determine if patient has consented to share
    protected information
  • Consent refers to documents, document sections,
    or individual data elements that may be sent

Application of Metadata
  • Helps receiving EHR/HIO implement access control
  • Electronic enforcement of prohibition against
    redisclosure of information
  • Provides a reference to a consent document that
    controls the data

Query Health
What is Query Health?
  • Objective
  • Enable a learning health system to understand
    population measures of health, performance,
    disease and quality, while respecting patient
    privacy, to improve patient and population health
    and reduce costs.

Improve community understanding of patient
population health
Summary Query Health Specifications and
  • Query Health must standardize how queries are
    asked, how they are returned, and how the
    information travels between parties.

Specification Definition Standard
Query Envelope A means to package the query and results along with security/privacy requirements, as well as other instructions PopMedNet Query Envelope
Query Format The way in which a query is constructed, its code, vocabulary etc. HQMF- Health Quality Measures Format
Results Format The way in which a result is reported, its code, vocabulary etc. QRDA- Quality Reporting Document Architecture
Policy Sandbox
  • Query requests and responses shall be implemented
    in the pilot to use the least identifiable form
    of health data necessary in the aggregate within
    the following guidelines
  • Disclosing Entity Queries and results will be
    under the control of the disclosing entity (e.g.,
    manual or automated publish / subscribe model).
  • Data Exchange Data will be either 1) mock or
    test data, 2) de-identified data sets or limited
    data sets each with data use agreements1 or 3)
    a public health permitted use2 under state or
    federal law and regulation.
  • Small cells For other than regulated/permitted
    use purposes, cells with less than 5 observations
    in a cell shall be blurred by methods that reduce
    the accuracy of the information provided3.
  • Notes
  • It is understood that de-identified data sets do
    not require a data use agreement, but in the
    abundance of caution, and unless otherwise guided
    by the Tiger Team or HIT Policy Committee, the
    pilot will have data use agreements for
    de-identified data
  • For a public health permitted use, individually
    identifiable health information may be provided
    by the disclosing entity to the public health
    agency consistent with applicable law and
  • The CDC-CSTE Intergovernmental Data Release
    Guidelines Working Group has recommended limiting
    cell size to three counts presuming a
    sufficiently large population. This is also
    reflected in Guidelines for Working with Small
    Numbers used by several states.

Query Health and Part 2
  • In future, Query Health technology may be used to
    query identifiable patient information
  • Must prevent identifiable Part 2 information from
    being returned in response to a query
  • Privacy metadata to restrict information from
    being queryable
  • Metadata in query envelope to communicate
    sensitivity when information allowed to be shared

State Health Policy Consortium (SHPC) -
Behavioral Health Data Exchange Consortium
  • Pilot the interstate exchange of behavioral
    health treatment records among treating health
    care providers using Nationwide Health
    Information Direct protocols
  • Draft Policies and Procedures (PP) for exchange
    of behavioral health treatment records
  • The focus is on meeting the requirements of
    federal regulations at 42 CFR Part 2 and meeting
    mental health laws of consortium states

  • Consortium States are Alabama, Florida,
    Kentucky, Michigan, Nebraska and New Mexico
    representatives include legal and behavioral
    health subject matter experts
  • Each state is to recruit Behavioral Health
    providers and other providers that might exchange
    with Behavioral Health providers to participate
    in the pilots
  • Representatives of the ONC, Substance Abuse and
    Mental Health Services Administration, the Legal
    Action Center and subject matter technical
    experts on the NwHIN Direct protocols

Workflow Scenarios for Discussion
Workflow 2 Update PCP
  • Workflow 1 Request for info
  • Workflow 3 referral
  • At end of patients stay, New Mexico provider
    (who is a Part 2 program and a mental health
    provider) sends patient summary to patients PCP
    in Kentucky
  • Florida Part 2 program requests patients records
    from prior stay at Michigan behavioral health
    provider facility (a Part 2 program)
  • Alabama PCP sends referral to Florida Part 2

Workflow 1 Request for Info
Send request for records along with patient
Receive request for records along with patient
Send patient records specified in patient consent
Receive requested patient records
Michigan Part 2 Program
Florida Part 2 Program
Jane Patient
Signs consent
Workflow 2 Update PCP
Sends visit summary and clarifying info
Receives visit summary and clarifying info
Jane submits clarifying info
Kentucky Primary Care Provider
Jane Patient
New Mexico Part 2 Program Mental Health Provider
Signs consent
Workflow 3 - Referral
Receives referral
Sends referral
Jane Patient
Alabama Primary Care Provider
Florida Part 2 Program
Future Treatment
State HIE Community of Practice Privacy and
Security Workgroup on42 CFR Part 2
State HIE 42 CFR Part 2 Community of Practice
  • Discuss compliance approaches for listing
    entities, including location, formatting, and
    effective business processes for updates.
  • Present examples of break the glass access and
    the feedback loop. The focus will be on map
    process requirements, formatting, and
  • Explain required notices and limitations on the
    re-disclosure of protected information
  • Discuss data protection and how data may be
    shareable in a query-based HIE environment

  • Now for your questions...

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Thank you
  • Prepared in 2012 by
  • the Legal Action Center,
  • under a subcontract from
  • Partners for Recovery
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