Transforming Service Delivery

Supporting Behavioral Health Information Exchange

June 14, 2019

2019 WA Behavioral Healthcare Conference

Agenda

• Survey of HIT Adoption by BH Providers

• The Support Act

• Substance Use Disorder (SUD) and Mental Health(MH) IMD Waivers: HIT Provisions

• HCA Recommendations to Advance Health Information Exchange (HIE): Comments on CMS Rules

• Social Determinants of Health (SDOH)

• Discussion: What do you need/want from HIT/HIE?

• Resources

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HIT Survey of BH Providers

2019 Behavioral Health Provider Survey

(As of 2/20/2019)

What record keeping system do you use?

• About 20% of MH agencies reported using paper compared to about a third of SUD agencies (31%) and less than 10% of MH-SUD agencies.

• Regardless of type and size, about 85% of BH agencies reported using either an EHR (48%) or a Certified EHR (CEHR) (36%).

• 16% of small and 14% of medium sized agencies reported using paper compared to 11% of large agencies.

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AGENCY TYPE AGENCY SIZE

MH SUD MH-SUD Total Small <=10 Medium

11-74

Large

>=75

Total

Paper 22 (20%) 13 (31%) 11 (8%) 46 (16%) 17 (16%) 18 (14%) 2 (11%) 37 (15%)

EHR 50 (45%) 23 (55%) 62 (47%) 135 (48%) 49 (46%) 69 (55%) 7 (37%) 125 (50%)

CEHR 39 (35%) 6 (14%) 58 (44%) 103 (36%) 40 (38%) 38 (30%) 10 (53%) 88 (35%)

TOTAL 111 (100%) 42 (100%) 131 (100%) 284 (100%) 106 (100%) 125 (100%) 19 (100%) 250 (100%)

Source: HCA/DBHR Survey – Preliminary Findings

2019 Behavioral Health Provider Survey (As of 2/20/2019)

Do you have plans to transition to an EHR?

• Almost all agencies using paper, regardless of type and size, reported

having plans or are thinking of transitioning to EHR except for 14% of

MH and 12% of small agencies.

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AGENCY TYPE AGENCY SIZE

MH SUD MH-SUD Total Small

<=10

Medium

11-74

Large

>=75

Total

Yes 14 (64% 8 (62%) 11 (100%) 33 (72%) 9 (53%) 18 (100%) 1 (50%) 28 (76%)

Thinking 5 (23%) 5 (39%) 0 (0%) 10 (22%) 6 (35%) 0 (0%) 1 (50%) 7 (19%)

No 3 (14%) 0 (0%) 0 (0%) 3 (6%) 2 (12%) 0 (0%) 0 (0%) 2 (5%)

TOTAL 22 (100%) 13 (100%) 11 (100%) 46 (100%) 17 (100%) 18 (100%) 2 (100%) 37 (100%)

Source: HCA/DBHR Survey – Preliminary Findings

When do you plan to transition to an EHR?

• Regardless of type and size, approximately 60% of agencies are planning

or thinking of transitioning to an EHR in the next 6 months.

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AGENCY TYPE AGENCY SIZE

MH SUD MH-SUD Total Small <=10 Medium

11-74

Large

>=75

Total

Next 6 mos. 8 (42%) 10 (77%) 7 (64%) 25

(58%)

6 (40%) 13 (72%) 2 (100%) 21 (60%)

Next year 5 (26%) 1 (8%) 2 (18%) 8 (19%) 4 (27%) 3 (17%) 0 (0%) 7 (20%)

2 years 3 (16%) 1 (8%) 2 (18%) 6 (14%) 2 (13%) 2 (11%) 0 (0%) 4 (11%)

Other 3 (16%) 1 (8%) 0 (0%) 4 (9%) 3 (20%) 0 (0%) 0 (0%) 3 (9%)

TOTAL 19 (100%) 13 (100%) 11 (100%) 43

(100%)

15 (100%) 18 (100%) 2 (100%) 35 (100%)

2019 Behavioral Health Provider Survey (As of 2/20/2019)

Source: HCA/DBHR Survey – Preliminary Findings

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The Support Act

The Support Act

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• Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (enacted October 24, 2018)

• Key provisions include:

– EHR Incentive payments to Behavioral Health (BH) providers (Section 6001)

– Qualified Prescription Drug Monitoring Program (PDMP) (Section 5042)

– Amendments to Child Abuse Prevention and Treatment Act (CAPTA) (Section 7065 (a))

https://www.congress.gov/bill/115th-congress/house-bill/6/text#toc-H332DF82BFDE94DAB85210F4D2222CBF8

BH Providers EHR Incentives SEC. 6001. Testing of incentive payments for behavioral health providers for adoption

and use of certified electronic health record technology.

Section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 1315a(b)(2)(B)) is amended by adding:

“(xxv) Providing, for the adoption and use of certified EHR technology (as defined in section 1848(o)(4)) to

improve the quality and coordination of care through the electronic documentation and exchange of health

information, incentive payments to behavioral health providers (such as psychiatric hospitals (as defined in

section 1861(f)), community mental health centers (as defined in section 1861(ff)(3)(B)), hospitals that

participate in a State plan under title XIX or a waiver of such plan, treatment facilities that participate in such a

State plan or such a waiver, mental health or substance use disorder providers that participate in such a State

plan or such a waiver, clinical psychologists (as defined in section 1861(ii)), nurse practitioners (as defined in

section 1861(aa)(5)) with respect to the provision of psychiatric services, and clinical social workers (as defined

in section 1861(hh)(1))).”.

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https://www.congress.gov/bill/115th-congress/house-bill/6/text#toc-H332DF82BFDE94DAB85210F4D2222CBF8

Qualified PDMP

The Support Act makes available 100% federal funds for expenditures related to a Qualified PDMP during Federal Fiscal Years 2019 and 2020 if the State has agreements with all contiguous states (i.e., ID and OR) that enable covered providers in all such contiguous States to access, through the PDMP, certain information.

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Qualified PDMP 1. A Qualified PDMP must facilitate access to the following information:

– prescription drug history of a covered individual with respect to controlled

substances

– number and type of controlled substances prescribed to and filled for the covered individual during at least the most recent 12-month period

– name, location, contact information of each covered provider who prescribed a controlled substance to the covered individual during the most recent 12-month period.

2. A Qualified PDMP facilitates integration of information into the workflow of a covered provider, which may include the electronic system the covered provider uses to prescribe controlled substances.

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Qualified PDMP – Funding Request

• HCA, in collaboration with the DoH, submitted a funding request to CMS to access the 100% federal funds for:

– a PDMP solution

– technical assistance to assist providers with integrating PDMP data into the workflow of their EHR systems

– interoperable HIT to support the integration of the PDMP and CDR:

• electronic consent management,

• availability of additional clinical data sources, and

• reporting for clinical and case management.

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IMD Waivers

1115 IMD Waivers: Background

• Federal rules prohibit Medicaid funds for services to individuals who reside in an Institution for Mental Disease (IMD) for more than 15 days during a calendar month.

• SUD IMD Waiver: In 2016, CMS offered states the opportunity to apply for an 1115 demonstration waiver allowing Medicaid-funded treatment in SUD IMDs.

• MH IMD Waiver: In 2018, an Executive Order permitted 1115 waivers for Medicaid funded MH services in IMD facilities.

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1115 SUD IMD Waiver

SUD IMD Waiver

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• In July 2018 Washington State was granted an 1115 waiver amendment to its Medicaid Transformation Program (MTP) for SUD IMD facilities.

• This IMD Waiver permits Medicaid coverage of SUD services in “IMDs” with more than 16 beds

• The MTP/ SUD IMD Waiver requires:

– reporting milestones; and

– SUD HIT Plan

SUD IMD Waiver HIT Plan • SUD HIT Plan identifies tasks to achieve activities identified by CMS

• HCA added Financial Mapping Task and made all other Tasks contingent on funding

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SUD HIT Plan Tasks

Conduct Financial Mapping Provide reports on clinician long-term opioid prescribing patterns

Establish agreements for interstate data sharing through a PDMP

Convene clinical EMR users to describe desired workflow for accessing the PDMP via the CDR

Support the “ease of use” of the PDMP Develop a function to allow providers within the CDR clinical portal to access the DOH-operated PDMP

Enhanced connectivity between the state’s PDMP and HIE-organizations

Work with the HHS multi-agency Enterprise Governance process (e.g., HCA, DoH, DSHS, DCYF, HBE) on: • master patient index (MPI) strategy for PDMP query • Patient/provider matching

• Significant overlap in “Qualified PDMP” and SUD HIT Plan.

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1115 MH IMD Waiver

MH IMD Waiver

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• Washington State is applying for an 1115 waiver amendment to its MTP for MH IMD facilities.

• This IMD Waiver permits Medicaid coverage of MH services in “IMDs” with more than 16 beds

• The MTP/ MH IMD Waiver requires:

– reporting milestones; and

– MH HIT Plan

MH IMD Waiver / HIT Plan • CMS requires the following assurances and tasks in the HIT Plan:

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Assurances: 1. The state has (or will have) sufficient health IT infrastructure at every appropriate level

(i.e., state, delivery system, MCO and provider level) to achieve demonstration goals. 2. The state commits to aligning its HIT Plans. 3. The state commits to assess the applicability and inclusion of certain national standards

in MMCO contracts, including at a minimum, standards for: referrals, care plans, consent, privacy and security, data transport and encryption, notification, analytics and identity management

MH Waiver HIT Plan

Closed Loop Referrals and e-Referrals Telehealth to integrate MH and primary care

Create and use Electronic Care Plans Analytics

Medical Records Transition Technology for care coordination

E-consent Identity Management

Interoperable Intake, Assessment, and Screening tools

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HCA Recommendations to Advance HIE:

Comments on CMS Rule

CMS Proposed Rules

• CMS (and ONC) published NPRMs to Advance Interoperability. – https://www.cms.gov/Center/Special-Topic/Interoperability/CMS-9115-P.pdf

– https://www.healthit.gov/sites/default/files/nprm/ONCCuresActNPRM.pdf

• Comment period closed June 3

• HCA comments:

– https://www.hca.wa.gov/about-hca/health-information-technology/washington-state-medicaid-hit-plan

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Overview of HCA Comments on CMS Rule

• Recommend CMS, SAMHSA, and ONC collaborate to:

– link SAMHSA required TEDS Data Elements (DEs) with HIT standards and encourage use

– identify functional status domains and DEs applicable to persons with BH conditions and Intellectual and Developmental Disabilities, and encourage use

– set aside of a minimum percentage of SAMHSA Block Grant funds for HIT/HIE

– align 42 CFR Part 2 with HIPAA

– incentivize adoption and use of interoperable HIT systems / data by BH providers

– implement grant programs to test interoperable HIE with and by BH providers/others

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SDOH

Gravity Project

• National, public collaboration on SDOH focusing on:

food security, housing stability/quality, and transportation access.

• Goals:

– Develop use cases for: screening, diagnosis, treatment/intervention, and planning within EHRs/ related systems

– Identify DEs and develop consensus-based recommendations on DEs for interoperable exchange and aggregation

– Start development of an HL7® FHIR Implementation Guide

• Work complete by Dec. 2019

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Gravity Project (SDOH)

• Home page:

https://confluence.hl7.org/display/PC/The+Gravity+Project+Home

• Join:

https://confluence.hl7.org/display/PC/Join+the+Gravity+Project

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Discussion

Discussion

• What do you need/want from HIT/HIE?

• How does HIT/HIE fit into or disrupt your workflow?

• What technology solutions/supports do you need?

• What barriers (e.g., technology, policy, other) need to be addressed to support your use of HIT/HIE?

• What information would you like to see in the CDR?

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Resources

HCA HIT Resources

Materials available at the HCA/HIT website include:

• State Medicaid HIT Plan (SMHP)

• HIT Strategic Roadmap and Operational Plans

– Comments on CMS and ONC rules

• Technical Assistance materials

https://www.hca.wa.gov/about-hca/health-information-technology/washington-state-medicaid-hit-plan

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Monthly HIT Operational Plan Meetings

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• 4th Tues. of every month-Next meeting June 25

• Same webinar, phone number, meeting room. Available at: https://register.gotowebinar.com/register/4052018503263997185

Questions?

Jennie Harvell,

Health IT Section

jennie.harvell@hca.wa.gov

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An overview of the Clinical Data

Repository (CDR)

Health Care Authority

Health Information Technology Section

Dennis Worrell

Health IT Stakeholder Engagement Manager

June, 2019

• Fun fact!

• History

• HIE background

• CDR explanation

• CDR web portal view

• Costs

• Fun fact review!

• Next steps

Agenda

Fun Fact!

3

First successful open heart

surgery performed by …?

And in what year …?

Secure Health Information Exchange

e-health

data

base

Primary

care

physician

LabTherapist

Pharmacy

Lab results

Lab resultsPharm data

Pharm data

VitalsVitals

Specialist Vitals PsychiatristRX

Pharm data

Lab results

How did we get here?

Natural and/or

other disasters,

Need for info

ARRA$

HITECH$

2002: OneHealthPort

founded

2009: WA appoints HCA

lead agency driving

interoperability

2009: OneHealthPort

wins competitive bid to

host WA’s Health

Information Exchange

(HIE)

2016: submissions begin!

To date: 6,000+ providers

and 88 hospitals = $355

million + in funding

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What is OneHealthPort’s HIE?

6

DOH

Electronic Lab Reporting

Syndromic Surveillance

PDMP

Cancer Event Reporting

LNI

Activity Prescription

Form

Submitting

Organization

(Electronic

System)

About 1,400 trading

partners (most

NRAA), plus all WA

hospitals

Health

Information

Exchange

Secure

connection

OneHealthPort

maintained

Provider

maintained

PDMP data

What is the Clinical Data Repository?

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CDR

Secure, web-

based database

storing clinical

and claims info

for Apple

Health

(Medicaid)

enrollees

Provider

EHR

Health

Information

Exchange

Secure

connection

OneHealthPort

maintained

Provider

maintained

Future State!

-Other data sets after consent

mgt. tools (SUD, STI, etc.)

-Only data from physical health

providers now

Client:

Improved

Care at

the Point

of Care!

CDR

How to access CDR data.

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EHR EHR

Client 1 Info

Client 2 Info

Provider

Tablet or PC

View-only web portal

Client 3 Info

Future State!

Providers can

query (auto-pull)

info from the CDR

to their EHRs

Health Information Exchange

Same EHR

brands?

Provider

EHR,

brand A

Seamless electronic

exchange of client

health data!

Specialist

EHR,

brand A

Different

EHR brands

& no CDR?

Provider

EHR,

brand A

Specialist

EHR,

brand B

No e-exchange!

Fax, telephone, courier

Different

EHR brands

& CDR?

Provider

EHR,

brand A

CDR

Specialist

EHR,

brand B

Client

e-data

Client

e-data

What’s in the CDR?

CDR

Clients with

Claims Data:

over 94%

Clients in system:

2.2 million

(active & inactive)

Active client

coverage:

about 50% as of

November 2018

Future State!

-Mental health data

- SUD data (incl.

methadone) with

CFR42 part 2

consent mgt.

solution

Incentive for Providers to participate?

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MCO contracts with providers:

If an organization answers yes

to all three, it is required to

participate in the CDR.

Part of MCO

provider network

serving Apple

Health Clients?

Have a

“Certified EHR”?

Received Medicaid

or Medicare EHR

Incentive Payment

Funding

Can’t say yes to all three?

Participation is not

required...at this time

What Info gets in the CDR?

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Procedures

Results

Functional

Status

Plan of

care

Advance

Directives

Immuniz-

ations

Family

History

Allergies

Social

History

Vital

Signs

Medical

Equipment

Medi-

cations

Problems

Mental

Status

Nutrition Payers

Patient

demo-

graphics

E-Version:

Clinical

Care

Record

What is a Continuity of Care

Document? (CCD)

Human-readable CCD

Web Portal: Summary View

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Web portal results graph

CDR supports role based access (RBA)

Normal•Stitches, set limb, office visit

•Front office?

Restricted•Stigmatizing info

•MD, RN, MA?

Very

restricted

•Stigmatizing info: STI, BH or

SUD diagnosis

•MD, RN, MA?

Sending provider sets restriction level

Alternatives

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Do Nothing ??

• Not really an

option...

Wait ??

• Hope vendors

create

interfaces

between

disparate

Electronic

Health Records

Systems

Take the

Lead!

• Create Data

Base

• Vendor-neutral

• Standards-

based

• Supports

national

certification

standard

• CMS & ONC

Summary of current & future benefits

Comprehensive

patient summary

EHR Vendor-

neutral,

standards-based

Common place,

providers working

with many MCOs

Aggregates data

to coordinate care

No EHR? Web

portal!

Additional

sponsors (DSHS,

PEB, private)

Patient historyFuture reporting

(HEDIS?)

New features: PMP

link+ more!

Supports VBPTrack high-

utilizers

Reduce

duplicative

procedures or

establish baseline

Costs

Organization level Annual Net Patient Revenue Annual Subscription fee

Entry $0 - $10 Million $600

Small $10 Million - $100 Million $6,000

Mid-size $100 Million - $500 Million $12,000

Large $500 Million - $1 Billion $24,000

Leadership $1 Billion Plus $48,000

CDR use?

Join HIE, sign trust

framework (must

be HIPAA CE)

Cost?

Annual

Based on annual

net patient revenue

Connecting?

Work with your EHR

vendor and OHP on

connecting

Year one, no-cost!

Contact

OneHealthPort

Health care

provider

• Doctors, clinics,

psychologists,

dentists,

nursing homes,

pharmacies

• …if they

transmit

electronic info

HHS has a

standard for

Health plan

• Health ins

companies,

HMOs, company

health plans

• Government

paid-for health

care (Medicaid,

Medicare, etc.)

Health care

clearinghouse

• Entities

processing

nonstandard

health info into

standard health

info (electronic

conversion)

What is a HIPAA covered entity?

As defined by HHS

Fun Fact!

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First successful open heart

surgery performed by …?

And in what year …?

Fun Fact!

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• Dr. Daniel Hale Williams III,

African-American

• 1893, Provident Hospital,

Chicago.

• With limited equipment!

• Patient, recovered in 51

days and lived 50 more

years.

Next Steps

• Find more about the CDR initiative at:

www.onehealthport.com/hca-cdr

• Contact HCA’s Health IT team to

– Schedule presentations and deeper dives

with HCA or OneHealthPort’s technical team

– Suggest ideas for use cases:

• healthit@hca.wa.gov, 360-725-1514

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Appendices

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