On March 8 the Providence Center, a community mental health provider in Rhode Island, submitted its first live record for Direct secure e-mail exchange. On March 21, it began fully automated health record uploads to the statewide health information exchange, CurrentCare. The providers say Rhode Island is the first state to share behavioral health and physical health information through the statewide HIE.
For behavioral health providers, the road to interoperable patient data is even bumpier than it is for those in other clinical settings. Largely due to concerns about federal privacy laws, behavioral health providers—even those using electronic health records—have so far been left on the sidelines by most HIEs. Federal confidentiality regulations commonly referred to as 42 CFR Part 2 state that without written authorization from the patient, physicians cannot access patients’ substance use history and current treatment regimen, except in cases of emergency. With so much else on their plates, HIEs have largely put off trying to solve the challenges around sharing this data.
In addition to those privacy concerns, only psychiatrists and nurse practitioners in behavioral health are eligible for meaningful use incentive payments. So it was quite an accomplishment for both the Providence Center and CurrentCare to go live with data exchange. During a March 25 webinar put on by the federal SAMHSA-HRSA Center for Integrated Health Solutions (www.integration.samhsa.gov), Bill Cadieux, CIO of Providence, and Charlie Hewitt, director of HIE product delivery for the Rhode Island Quality Institute, which runs CurrentCare, talked about some keys to their success.
Providence Center serves about 12,000 people per year with mental health, addiction and primary care problems. It has had an EHR since 2007.
Cadieux said his organization had to overcome several technological, cultural, workflow and privacy issues. “It is one thing to walk a tight rope between buildings, but another all together to do it a thousand times a day, day after day, and that's what you are talking about when interfacing,” Cadieux said. One workflow challenge is that the data is not embedded in the EHR. You have to log into CurrentCare to look for patient records, so at the beginning of the project when enrollment was low, it could be discouraging if only one in 10 clients a provider looks up is in the system. Culturally, Providence got a lot of pushback from the staff about sharing behavioral health data. “But what we found was that for the most part, our clients didn't share the same view,” he said.
There are basically two approaches to 42 CFR’s much tighter controls on health data. The first is to segment out the substance abuse data using
technology. But it is nearly impossible to provide a complete picture of a person's health while blocking all information about a substance abuse issue, Cadieux said. “The other is to use an all-or-nothing approach to participate in the exchange and that's what we have done. We will enroll a client in CurrentCare, but we will not upload any data without their release.”
The project to advance integration between behavioral and physical healthcare is a major priority in Rhode Island, Hewitt said, and the information is flowing in both directions. Behavioral health providers access it to see the medical health information that's provided by hospitals and pharmacies, and medical providers are able to access the information that's coming from places like the Providence Center.
CurrentCare is a secure repository of health care data of people who are enrolled. Rhode Island is an opt-in state, he explained. It requires CurrentCare to have the permission of the patient before it can collect any information. At this point, about one in three citizens — or about 300,000 people — have opted in to participate in CurrentCare. “We are collecting data from several different sources,” he said, including about 85 percent of the lab results generated in Rhode Island. Most of the state’s hospitals are providing admission and discharge information. And about 90 percent of the dispensed prescriptions come through a data feed facilitated by Surescripts. A number of individual practices have enabled their own instance of their EHR to send CurrentCare information in the form of CCDs (Continuity of Care Documents).
Once that information is in CurrentCare, providers access it through the CurrentCare viewer. The access is permitted only to treating providers that the patient specifies or in an emergency, Hewitt explained. No one else can access the information in CurrentCare unless they have a treating relationship, and that is enforced by a data use agreement that it enters into with each provider when they decide they want to subscribe.
So how does the behavioral health information flow? The client enrolls in the HIE, and also must give consent to the organization to release their data from CurrentCare. If the provider needs to know the information that pertains to substance abuse, for example, then the provider can access the tab in the viewer called the “part II tab” and at that point receives a message that says in effect you must assert again that you have a treating relationship with this patient and that you agree to the terms of redisclosure, which is a federally specified message on data that's originated at part II organizations. That provider must get the patient's consent before redisclosing this information to anyone else. When the provider clicks to agree to that statement, then one of two things will happen: If there is no information from part II programs, they will get a message that says there isn't any information. But if there is information, the information will flow. And the provider can view the information through this part II filter.
All of the community mental health organizations in Rhode Island have signed up to use CurrentCare. There are nine organizations operating 32 different sites.
“What's been hard is to get the providers to actually use the viewer once they have signed on and subscribed to it,” Hewitt said. “Many have signed up, but only a few have embedded it in the workflow. The ones that have embedded it in the workflow are actually very strong advocates for the use of the viewer. It is saving them time, but it has been hard to get the providers to take that step to actually get in there and use it.”
What's particularly interesting to them is a comparison of the medications that have been prescribed vs. dispensed medications. “The provider can get a very good view of what's going on with the patient,” he said.
It would be valuable if EHR vendors would make a small change to their systems so that at the end of an encounter, the system would automatically generate a CCD and attach it to a Direct message and send it off to CurrentCare, Hewitt said.
All nine Rhode Island mental health organizations are adopting Direct messaging. Yet getting the use of Direct messages integrated into work flow has been a challenge. In many cases it involves managing yet another e-mail account — or that's what it looks like to the providers. “Getting the providers to understand the value of this type of messaging,” Hewitt said, “and to see what it can be used for has certainly been a challenge so far.”
