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Innovative Technologies: Improving Practice, Protecting Privacy
NC PIC Innovative Technologies Summit Raleigh, NC March 12th, 2014
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director
Center for Substance Abuse TreatmentSubstance Abuse Mental Health Services Administration
U.S. Department of Health & Human Services
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Medical information will follow consumers so that they are at the center of their own health care.
Consumers will choose providers and hospitals based on clinical performance results available to them.
Clinicians will have an individual’s complete medical history, computerized ordering systems, and electronic reminders to improve quality of care.
President Barack Obama
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Eastern Carolina University (ECU) and N.C. DHHS Leading the Way
“There are a lot of other things that get publicity, but the thing that keeps me awake at night is substance abuse and mental health.” N.C. Governor McCrory• New N.C. DHHS $4 million dollar statewide telepsychiatry initiative
• Based on ECU’s Center for Telepsychiatry and e‐Behavioral Health & the Albemarle Hospital Foundation Telepsychiatry Project
• Establish links between hospital emergency departments & mental health professionals who can initiate treatment for ED patients who are experiencing mental health/substance abuse crises
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Today’s Behavioral HIT Topics
Improving Practice
Protecting Privacy
SAMHSA’s Solutions
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Improving Practice
Protecting Privacy
SAMHSA’s Solutions
Today’s Behavioral HIT Topics
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Interoperable HIT for Seamless, Integrated, Comprehensive Health Care
Hospitals
Pharmacies, PDMPs
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Community Services
Insurance Providers
SubstanceAbuse Treatment Programs
Primary Care
Mental Health Services
Consumer Centric Health Information
Exchange
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U.S. National HIT Landscape
HITECH Act: Large national investment in HIT; largely excludes BH providers.
Health Reform & the ACA: Coordinated, integrated, client‐centered care; expanded consumer base & transformation of service delivery and payment models; MHPAEA.
Privacy and Confidentiality Regulations: HIPAA; HIPAA Omnibus Rule; &42 CFR Part 2.
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Improving Practice: SAMHSA’s Behavioral HIT Strategic Initiative
Ensure that 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.
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.
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SAMHSA’s Behavioral HIT Objectives
Increase the involvement of BH organizations and providers in HIT initiatives including Health information Exchanges (HIE), EHRs, and PDMPs.
Increase the number of BH organizations meeting meaningful use activities.
Address the issues of privacy and security associated with mental illness and substance use disorder treatment.
Expand working relationships & collaborations across the public health and health care fields.
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SAMHSA’s Behavioral HIT Goals
Develop infrastructure for interoperable EHRs, including privacy, confidentiality, and data standards.
Support initiatives to develop/expand interoperability between various data systems including HIEs, EHRs, and PDMPs.
Provide incentives and create tools to facilitate the adoption of HIT with behavioral health functionality in general and specialty healthcare settings.
Deliver technical assistance to State Health IT efforts; behavioral health providers; & and other stakeholders.
Enhance HIT capacity, functionality, and accuracy to assess & improve quality‐of‐care and patient outcomes.
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Examples of SAMHSA Behavioral HIT Projects
Collaborations with public & private partners to enhance & expand HIT capacity & interoperability.
TCE‐Technology Assisted Care Grants. Grants for OTPs to adopt or upgrade to certified
EHRs. Incorporating HIT into SBIRT. Using new media to prevent Substance Abuse &
HIV/AIDS. Mobile App Challenges. Open source module development.
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Using HIT to Increase BH Client Engagement
HIT has tremendous potential to increase the engagement of BH clients in their own care.• Provide individuals with health information tailored to their own risks and health literacy
• Provide links to community and online resources• Provide tools to support self‐care & shared decision making– Goal setting and tracking– Supporting adherence – Interfacing with mobile health tools
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Applying HIT BH Performance Measures
HIT BH performance measures 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 define & demonstrate success?
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Behavioral HIT Stakeholder Engagement
SAMHSA held three HIT Regional Forums:• Participants were from 50 states and U.S. territories.
• Objective: 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.)
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Behavioral HIT Stakeholder Concerns
Matching evolving business practices with evolving trends in treatment.
Interoperability (e.g, compatibility of legacy systems w/newer systems).
Not having the ability to receive Meaningful Use incentives.
Smaller practices lack the funds to be able to successfully implement EHR.
Lack of resources to properly educate staff on the proper use of EHR.
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Behavioral HIT Challenges
How should HIT systems be designed to control disclosure and re‐disclosure of BH sensitive information?
How can we ensure that when BH data are shared they are interpretable across providers and by third parties (e.g., researchers, public health, surveillance)?
How can BH systems evolve rapidly along with research and changing best practices?
How can new technologies take us to the next level of BH care delivery?
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Behavioral HIT Challenges (cont.)
How can technologies be used to reduce BH reporting burdens while improving data quality?• Minimize data re‐entry• Harmonize across programs to data elements collected in the normal course of care delivery
How can BH systems share information with other service agencies? For example:• Criminal Justice• Housing and Urban Development• Local & Regional Public Health and Social Services Agencies
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Improving Practice
Protecting Privacy
SAMHSA’s Solutions
Today’s Behavioral HIT Topics
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HIT & BH Privacy
http://funnyjokesandlaughs.wordpress.com/tag/technology/
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Obligations and Responsibilities
Modern version of the Hippocratic Oath:
“I will respect the privacy of my patients, for their problems are not disclosed to
me that the world may know.”
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Consent cannot be valid if people can only obtain essential services by providing it.
Forced Consent is Not Consent
Br J Gen Pract. 2004 September 1; 54(506): 725 ; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1326097/pdf/bjpg54‐725.pdf
– James Willis, British Journal of GP
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Public HIT Concerns: Vulnerabilities
"The security tools that you put in place aren't really stopping us as hackers…it seems that time and time again, for us to get into medical systems or hospitals, it's very trivial.”
‐‐David Kennedy, founder & principal security consultant at TrustedSec
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Healthcare Information and Management Systems Society 2013http://www.healthcareitnews.com/news/dont‐look‐now‐youve‐been‐hacked
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In 2012, Kennedy performed about 150 penetration tests against hospitals:• "Out of those 150, not one of them stopped us from breaking in and taking all their data... With current technology, it's never been easier to break into an organization."
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Public HIT Concerns: Vulnerabilities (cont.)
Healthcare Information and Management Systems Society 2013http://www.healthcareitnews.com/news/dont‐look‐now‐youve‐been‐hacked
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Public HIT Concerns: Secrecy & Misuse
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Public HIT Concerns: Unintended Consequences
?
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Consumer Confidentiality and Trust
In order to achieve any level of systemic durability and success, HIT must be trustworthy and developers and managers must warrant & sustain trusting relationships with all participants, especially the public consumer.
Privacy is not an area for compromise. Confidentiality should never be a shortcut. Security should not be a second thought or an
afterthought.
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Privacy & Technology: Partners or Adversaries?
Data integration and aggregation, coupled with increased on‐line accessibility and sophisticated hacking, tracking, and data mining technologies, dramatically increase the risk and the consequences of breaches of privacy and confidentiality.
In turn, these elevated risks & consequences dramatically increase our obligations to ensure consumer choice; privacy & confidentiality; state‐of‐the science security; and rapid mitigation of unintended consequences.
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Remember the Purpose 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.
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Privacy & Best Care Possible: Ensuring Synergy
Consumer‐centric HIT
• Consent management: Consumer regulates access (privacy, confidentiality)
• Data segmentation & security
Consumer HIT education & engagement
HIT transparency, accountability, & consistency
HIT consumer alert systems
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SAMHSA’s Consent2Share (C2S)
SAMHSA has been working with the ONC S&I Framework and the VA to develop open source technology for consent management and data segmentation to give the consumer granular control over information sharing.• Support compliance with 42 CFR Part 2, Title 38, and state health privacy laws
• Open source tool that is being designed to integrate into existing EHR and HIE platforms
• http://wiki.siframework.org/Data+Segmentation+for+Privacy
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SAMHSA’s Consent2Share
http://www.youtube.com/watch?v=PzICMAb_cEQ
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Patient Privacy & Confidentiality: The Conversation Is Only Beginning…
Patient Privacy at Risk. The HHS IG found that the security policies and procedures at the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information
Technology are lax and may jeopardize sensitive patient data.
http://www.thune.senate.gov/public/index.cfm/press‐releases?ID=0e59289e‐9d0e‐4f9f‐992a‐027b3aba473e. REBOOT:Re‐examining the Strategies Needed to Successfully Adopt Health it .2013. US Senate.
http://oig.hhs.gov/oas/reports/region4/40805069.pdf.
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Improving Practice
Protecting Privacy
SAMHSA’s Solutions
Today’s Behavioral HIT Topics
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SAMHSA’s Behavioral HIT Portfolio
Since FY2010, SAMHSA has awarded over $43 million in funds for HIT projects and programs.
Approximately 54 grants have been awarded between FY2010 and FY2014.
HIT projects in 28 states have been funded.
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States with SAMHSA Funded HIT Grants
States with SAMHSA HIT grants
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SAMHSA’s HIT Portfolio is Diverse
SAMHSA’s HIT portfolio bridges a range of strategies: e‐therapy, telehealth, e‐Recovery, EHR systems, a Virtual Reality Clinic, Smartphone technology, web‐base virtual recovery, telephone counseling, telepsychiatry, automated wellness calls, pre‐admission web‐portals, and mobile strategies. • Projects focused on underserved populations such as individuals living with HIV/AIDS in rural areas
• Projects focused on vulnerable, high‐risk populations like veterans
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SAMHSA’s TCE‐TAC
Targeted Capacity Expansion (TCE) Technology Assisted Care (TCE‐TAC) Grants enables SAT programs to:• Expand care coordination through the use of
HIT.• Leverage technology to enhance or expand the
capacity of substance abuse treatment providers to serve persons in treatment who are underserved.
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East Carolina University TAC($276,277, 08/01/2013‐07‐31‐2‐16)
Military veterans are at a significantly high risk for substance abuse and co‐occurring mental health disorders.
This risk is compounded by the facts that veterans and their families (a) have a significantly greater chance of experiencing a homeless episode; (b) are more likely to experience these issues when representing minority sub‐populations such as racial/ethnic, gender, and/or sexual orientation minorities; and (c) are unlikely or unable to seek treatment due to a number of barriers including stigma or residing in a rural area.
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East Carolina University TAC Mission
The mission of the ECU TAC, Operation Reentry North Carolina: Veteran Resiliency and Reintegration Through Technology (ORNC:R&R), is to strengthen the resiliency and facilitate the reintegration of veterans through creative and innovative uses of technology.
The project is focusing on veterans struggling with substance abuse and co‐occurring mental health issues who live in rural, eastern North Carolina.
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Goals of ORNC:R&R include: • Deployment of clinical team in technology‐equipped van to conduct mobile outreach to veterans who are homeless or under‐served in rural, eastern, N.C.
• Service coordination with the VA homeless and rural health programs, and community‐based treatment providers and resources
• Provision of state‐of‐the‐art, evidence‐based interventions via telehealth, web, and application‐based service delivery systems
• Sharing of best practices & project results with providers in rural, eastern N.C.
East Carolina University ORNC:R&R Goals
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ORNC:R&R’s technology delivered interventions will be based on motivational interviewing, biofeedback training, community reinforcement approach, telepsychiatryconsultation, relational health consultation, and vocational counseling.
Targeted outcomes include: • Increasing the number of veterans and their families who access medical, psychiatric, and behavioral health services
• Reducing substance use and symptoms of co‐occurring mental health disorders (e.g., suicide, post‐traumatic stress, depression, etc.)
East Carolina University ORNC:R&R Interventions & Outcomes
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The U.S. Prescription Drug Epidemic
The nonmedical use of controlled prescription drugs (CPDs) continues to be the nation’s fastest growing drug problem.
Individuals abusing CPDs at a higher prevalence rate than any illicit drug except marijuana.
Pain relievers are the most common type of CPDs taken illicitly, and are the CPDs most commonly involved in overdose incidents.
http://www.justice.gov/dea/resource‐center/DIR‐017‐13%20NDTA%20Summary%20final.pdf
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Stemming the Flow:National Action Plan for PDMPs
Stakeholders
Organizations
White House Roundtable on
Health IT & Prescription Drug AbuseJune 3, 2011
Federal & State Partners
State Participants
Action Plan: Improving Access to PDMPs
through HIT
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SAMHSA’s Funding for the National Action Plan (Phases 1&2)
SAMHSA provided funding for implementation of the Action Plan through the “Enhancing Access to PDMPs through Health IT Project”.• SAMHSA partnered with ONC, ONDCP, & the CDC
• ONC has management oversight of the effort
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Improve real‐time access to PDMP via existing technologies like EHRs (FY12,13).
Strengthen operational state of PDMPs by increasing interoperability between states (FY12).
Evaluate the impact of the enhancements on Rx drug abuse (FY12).• FY 12: 2 year funding for 9 states (FL, IL, IN, KS, ME, OH, TX, WA, WV)
• FY 13: 2 year funding for 7 states (KY, MA, ND, NY, RI, SC, WI)
SAMHSA’s PDMP Grants
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U.S. Snapshot: PDMPs
Majority of U.S. localities have operational PDMPs.
VT has enacted PDMP legislation.
D.C. has PDMP legislation pending.
In MO, privacy concerns are 1 reason for push back on legislation.http://www.pdmpassist.org/pdf/pmpprogramstatus2013_a.pdf
http://www.komu.com/news/prescription‐drug‐monitoring‐program‐may‐curb‐state‐drug‐abuse/
12/23/2013
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U.S. Snapshot: PDMP Interoperability
24 States are engaged in interstate data sharing.
Engaged does not mean that a PDMP is sharing data with all of the other PDMPs.
http://www.pdmpassist.org/pdf/PDMP_interoperability_status.pdf
1/14/2014
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The Evergreen Treatment Services (ETS) OpioidTreatment Program (OTP) pilot in WA streamlined PDMP availability for prescribers by providing direct access from within their EMR system.
SAMHSA’s PDMP Solutions: Washington Case Study
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ETS pilot demonstrated the value of health IT connectivity & showcased the workflow, ease of use, and added technical value of improved access to the PDMP in the OTP clinical management system workflow.
SAMHSA’s PDMP Solutions: Washington Case Study (cont.)
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PDMP is valuable as a clinical decision support tool.
Integrating the PDMP into provider workflow reduces barriers to PDMP access and increases its utilization.
Type of integration can vary:• Basic integration is valued (e.g., hyperlink to PDMP & return PDF)
• Value increases with degree of automationPhase 3 of the National Plan is in process.
Key Takeaways of the National Action Plan for PDMPs (Phases 1&2)
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Opioid Misuse & Abuse: The Human Toll
In 2010, CDC reported >16,000 deaths due to poisoning by opioid analgesics; and >3,000 deaths due to heroin overdose.
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Reducing the Human Toll:SAMHSA‐Certified OTPs
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Reducing the Human Toll:SAMHSA’s OTP‐CoC Initiative
Enhancing Opioid Treatment Program Patient Continuity of Care through Data Interoperability.
Purpose: to provide resources to opioid treatment programs (OTPs) that will enable them to develop EHR systems that fulfill regulatory requirements, achieve certified status, and become interoperable with other patient health record systems.
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Health Care Integration:SAMHSA’s HIT Collaboration with HRSA
5 Sub‐awards supported sharing of health records among behavioral health providers and general medical providers through state HIEs (ME, KY, IL, OK, RI)
Develop infrastructure supporting the exchange of health information among behavioral health and physical health providers
Led by the National Council
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Identify barriers to inclusion of behavioral health in state HIEs.
Identify technology and policy solutions for compliance with federal and state regulations.
Develop a consent form template that is computable in a HIE Environment.
Primary challenge around technical capacity for consent management.
SAMHSA:HRSA HIE Grant Goals
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Worked with CMS to identify and track SAMHSA and its grantees in preparation for the transition to ICD‐10 diagnostic and procedures billing codes.
ICD 10 Implementation:SAMHSA’s HIT Collaboration with CMS
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The ASAM Patient Placement Criteria (PPC) is a multi‐dimensional patient assessment tool linked to a comprehensive set of clinical decision support guidelines for patients with addiction disorders. • Provides evidence based recommendations for level of treatment required
SAMHSA worked with ASAM to develop a web service for the ASAM PPC which can be integrated with existing EHR systems.• Pilot testing is ongoing• Software will be free and publicly available
Clinical Support Tools:SAMHSA’s HIT Collaboration with ASAM
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New Media & High Risk Populations: SAMHSA’s Minority AIDS Initiative
Minority AIDS Initiative (MAI) Program: Using New Media to Prevent Substance Abuse & HIV/AIDS for Populations at High Risk. • Utilizing new media to promote targeted SA and HIV prevention messages to selected racial/ethnic populations at high risk for SA and HIV infection.
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Mobile Technology: SAMHSA’s Mental Health App
Mental Health Recovery Appo Developing technical specifications for a mobile app to support patients in recovery from mental disorders and co‐morbid substance use disorders
Developing mHealth policyo Endorsement/certification and maintenance of apps
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Mobile Technology: SAMHSA‐Supported A‐CHESS App
Addiction‐ Comprehensive Health Enhancement Support System (A‐CHESS)• Connection with a support team (other ACHESS users)
• Photo sharing, discussion group and healthy event planning
• Use of GPS to detect when user is near a high‐risk location (for example, a liquor store)
• Video chat with counselor or discussion group
http://chess.wisc.edu/chess/projects/AddictionChess.aspx
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SAMHSA’s Prevent High‐risk Drinking among College Students Challenge:• Prevent high‐risk drinking among college students
through cost‐effective, portable, technology‐based products.
• Products to effectively reach college students, parents, administrators, faculty, and staff.– BeWise (Syracuse U.)– Expectancy Challenge Alcohol Literacy Curriculum
app (University of Central Florida)http://collegestudentdrinking.challengepost.com/
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SAMHSA’s Primary Care Suicide Prevention App Challenge• Assist in delivering evidence based practices to primary care providers whose patients present with suicidal ideation
• Develop mApp that provides care continuity and follow‐up linkages for someone at risk for suicide who was discharged from an inpatient unit or emergency department.– Relief Link , Emory University– MyPsych– ReachZ & Companion
http://suicidepreventionapp.challengepost.com/
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Closing Thoughts: The Future of Behavioral HIT
The HIT revolution is just beginningTechnology is evolving rapidlyMany of the tools that are being used now will be displaced by newer tools that support safer, higher quality, more efficient workflow
Focus needs to be on long term potential for improving health care services and delivery through HIT and other innovative technologies
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Lessons Learned Thus Far
Transitioning to new technologies takes patience.In rural areas, the lack of technology infrastructure to provide requisite bandwidth for operation of telehealth equipment limits our ability to reach telehealth goals.
Inflexible business relationships with vendors locks in programs to proprietary systems, which canprevent/impede adoption of more appropriatetechnology.
Data plans and service.
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Provider reluctance to adapt to the use of innovative technologies.
Staff reluctance to adapt to the use of new technologies.
Limited patient access to the internet and to smartphones.
Patient/client resistance.
Lessons Learned Thus Far (cont.)
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Looking Forward: Behavioral Medicine & the Web Data Revolution
Could Behavioral Medicine Lead the Web Data Revolution? Ayers et al. JAMA 2014.
Billions of digital footprints from nearly all parts of the United States and from countries around the world provide a powerful opportunity to expand the evidence base across medicine.• Behavioral medicine can be a leader in this web data revolution
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Thank [email protected]