Connecting behavioral health data and primary care

There are ongoing discussions among healthcare leaders about the need to integrate behavioral health data into primary care to improve quality of care. Two health information exchanges (HIEs) in Colorado have been working on behavioral health information integration projects and shared their initial progress during a webinar conducted by The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of the National Coordinator for Health Information Technology (ONC).

According to a SAMHSA 2011 national survey, 45.6 million American adults, nearly one in five, suffer from mental illness, and 8 million Americans have a substance abuse disorder. In addition, 29 percent of all people with a physical health condition also have a behavioral health condition; conversely, 68 percent of adults with a mental illness have at least one medical condition.

Many healthcare leaders argue that behavioral health information, such as medical history, lab results, medication lists and treatment plans, needs to be accessible in electronic exchange as the lack of that information in a person’s health record can put them at risk, potentially leading a provider to prescribe treatment that compromises the person’s safety or disrupts their recovery.

Kenneth Salyards, information management specialist at SAMHSA, said there are concerns about sharing behavioral health data due to ongoing bias and stigma regarding mental health or substance abuse problems. “It’s important that individuals retain the right to choose whether to disclose behavioral health data. HIEs can facilitate that,” he said.

A SAMHSA HIE survey indicates that many HIEs are beginning to integrate behavioral health data into HIEs, yet only 25 percent of HIE respondents are now electronically sharing data subject to 42 CFR Part 2 (alcohol and drug abuse patient records).

There are a number of federal and state laws governing the disclosure and exchange of sensitive health information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulates the use and disclosure of Protected Health Information (PHI) and there are  special privacy protections afforded to alcohol and drug abuse patient records by 42 Code of Federal Regulations (CFR) Part 2. Information protected by 42 CFR Part 2, which is information that identifies a patient as having a drug or alcohol problem, requires patient consent for disclosure.

The ability to handle patient consent electronically is one critical issue with sharing behavioral health data, and, according to the SAMHSA HIE survey, more than 50 percent of HIE respondents reported the capacity to handle consent management electronically, Salyards said.

As outlined during the webinar, there are two HIEs in Colorado, the Colorado Regional Health Information Organization (CORHIO) and the Quality Health Network (QHN), that are working to integrate behavioral health information into their HIE systems.

THE CORHIO HIE connects 49 hospitals, with 10 more on the way, and 2,700-plus providers and has 4 million patients in the community health record. According to Toria Thompson, behavioral health information exchange coordinator at CORHIO, the HIE conducted a two-year study into the barriers and opportunities for exchanging behavioral health data and issued the results of that study in 2012.

A number of recommendations came out of that report, such as including the behavioral health community in the development of a statewide health information exchange and supporting public policy to address barriers to information sharing, Thompson said. And, those recommendations have laid the framework and groundwork for CORHIO’s work in the past three years and moving forward. 

Working with the behavioral health community, CORHIO advocated for changes to state statute to align Colorado state law with the federal law. “This revision allowed mental health professionals to follow the information sharing best practices utilized by their colleagues in the medical profession,” Thompson said.

One key recommendation of the report was to modify CORHIO’s HIE operations to develop a granular consent model and enable consumer access to treatment data available within the exchange.

CORHIO and QHN are both currently working on pilot projects to test two different models for adding patient consent and sharing behavioral health data in HIEs with funding from an ONC grant through the Advance Interoperable Health Information Exchange Program.

The challenge of this project, Thompson said, was adding consent-based exchange to a HIPAA-based HIE.

CORHIO is currently in Phase 1 in building the architecture for a model adding patient-managed consent into the HIE. The model calls for a separate repository for protected, non-HIPAA shareable data from substance abuse treatment providers and community mental health centers, yet that data would be shareable only via consent, which is managed through a Patient Consent Portal. That data could then be redacted or shared based on patient consent as health records are exchanged with the CORHIO Provider Portal, Patient Care 360, which connects to the community health record.

In Western Colorado, QHN is taking a different approach to integrate behavioral health data into its HIE, according to Jane Foster, QHN clinical director. QHN is currently working on project with Mind Springs Health, a regional behavioral health organization providing services at 13 locations. The goal of the project is to securely exchange Mind Springs Health’s continuity of care documents (CCDs) and integrate them into the QHN patient longitudinal health records via a sequestered repository, Foster said.

According to Foster, the project was initiated by physicians and care providers in the region with had a shared vision to improve the community standard of care, with a specific focus on sharing patients’ medication information.

“Our physicians and care providers in the region came forward and said to the behavioral health community, ‘We refer patients and then never hear back. We don’t know how a patient’s treatment is going or what medications they are on, and it’s a quality of care issue. We can’t provide good primary care if don’t know what’s going on on the behavioral health side’,” Foster said.

While Mind Springs Health had been sharing information with authorized providers via fax, many providers found that it created workflow and security issues and wanted to move to electronic exchange, Foster said.

QHN authorized the expense and process changes to set up electronic exchange, such as developing new community-wide consent processes. About 16 months ago, QHN developed a new HIE platform, powered by health IT vendor Mirth, that enables a separate sequestered repository for sensitive health information and can work with both “push and pull” models, Foster said.

In this particular pilot, in a push model with referring providers, Mind Springs Health validates and secures the patient consent to share reports with referring providers, then sends the report via Direct to the HIE and the report is then “pushed” to the referring provider with the patient consent attached. The report is “wrapped’ and resides in the HIE longitudinal health record behind a secure “break the glass” view, or sequestered repository.

In the pull model, behavioral health records are pushed from Mind Springs Health to the HIE then “wrapped” and housed in the longitudinal health records in a sequestered repository under a special Consent Date Notice, which indicates that providers must have written patient consent prior to “breaking the glass.” Providers obtain patient consent using the established community-wide HIE consent form to view the behavioral health records.

“Our work with Mind Springs Health is a pilot and if it’s successful, then another Western Colorado regional mental health provider, with six locations, will be added to our behavioral health integration project,” Foster said. With that addition, a total of 19 behavioral health locations will be integrating their reports in the QHN HIE.

Foster and Thompson concluded that the projects underway indicate that HIEs can be an effective way to facilitate clinical information sharing to improve care. “It takes time and trust relationship building, and it’s easy to say the obstacles are too great, but the focus must be on what’s right for the patient to improve the standard of care,” Foster said.

During the webinar, Salyards with SAMHSA also outlined that ONC and SAMHSA are working together on a broad initiative, called the Data Segmentation for Privacy (DS4P) project, that aims to improve the ability to securely share sensitive health information, specifically substance abuse patient records. Phase One of the project, which took place from 2011 to 2014, demonstrated how standards can support current privacy policies to share sensitive health information across organizations and developed standards to enable sensitive electronic health information to be securely shared with authorized users.

Salyards also highlighted a number of collaborations between ONC and SAMHSA to integrate behavioral health information across the continuum of care, such as the development of Consent2Share, which is an open source application for consent management and data segmentation that integrates with electronic health records (EHRs) and HIEs. Consent2Share is compliant with privacy and confidentiality relations, including 42 CFR Part 2, Salyards said, and allows patients control over which health information they share with which providers.

Consent2Share is currently in production in an HIE in Prince George’s County in Maryland, he said.