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Welcome to :
Confidentiality, Substance Use Treatment, and Health
Information Technology
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Confidentiality, Substance Use Treatment, and Health Information Technology (HIT)
First 3 Webinars Presented by the Legal Action Center
4th Webinar Presented by SAMHSA
Four-Part Webinar Series on…
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Use the “Question(s)” feature on the upper right-hand corner of your screens to type in your question(s).
We will answer questions at the end of the presentation.
Have a Question During this Presentation?
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Today’s Power Point presentations can be downloaded from http://www.lac.org/index.php/lac/webinar-archive
Power Point presentations and materials from the Webinar series can be downloaded from http://www.lac.org and http://www.pfr.samhsa.gov The recording of this series will be available soon at the same locations.
Maureen Boyle, PhDLead Public Health Advisor, Health Information Technology
Center for Substance Abuse TreatmentSubstance Abuse and Mental Health Services Administration
May 25, 2012
SAMHSA’s Vision for Advancing SAMHSA’s Vision for Advancing Behavioral Healthcare throughBehavioral Healthcare throughHealth Information TechnologyHealth Information Technology
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President’s 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.
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“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 SebeliusSecretary
U.S. Department of Health & Human Services
September 29, 2009
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SAMHSA’s 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
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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
• HIPAA• 42 CFR Part 2• State laws
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Health Information Exchange
HIE
EHR
EHR
Claims
Data Systems
PHR
EHR
EHR
EHR
Public Health Agency
Health Plans
Clinics
HospitalsPrimary Care
Pharmacies
Labs
Patients
EHR
Specialty Care
NwHIN
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HITECH Act
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 summer• Multiple items of relevance to behavioral health
– Clinical Quality Measures– Privacy and Confidentiality
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Meaningful Use
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Stage 2
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Meaningful Use Incentive Program
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/eligibility_flow_chart.pdf
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Useful Links
CMS: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/
ONC: http://www.healthit.gov/providers-professionals/ehr-incentives-certification
Certified EHR: http://oncchpl.force.com/ehrcert/EHRProductSearch?setting=Inpatient
Regional Extension Centershttp://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__listing_of_regional_extension_centers/3519
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The Affordable Care Act
Establishing patient-centered medical homes (PCMH) and accountable care organizations (ACO)
Focus on coordinating care and pay for performance Formation of an ACO is contingent upon HIT for
information exchange and quality measure reporting
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Privacy and HIT
Privacy and Confidentiality Regulations• HIPAA• 42 CFR Part 2• State specific laws
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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
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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.
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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 personnel• 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
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MENTAL HEALTH CONFIDENTIALTY
Non-Substance Use Disorder mental health records may be treated as ultra-sensitive in many jurisdictions.
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.
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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 information
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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 (FAQs).
These FAQs can be accessed at: http://www.samhsa.gov/healthprivacy/docs/EHR-FAQs.pdf and
http://www.samhsa.gov/about/laws/SAMHSA_42CFRPART2FAQII_Revised.pdf
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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 systems
Even if the systems are in place, many do not have the personnel trained to effectively use them.
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SAMHSA’s Strategic Initiative - Health IT
The SAMHSA is working to advance Behavioral Health through Health IT• Technologies/policies for privacy and confidentiality• 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
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Solutions for Privacy
Working to identify interim solutions for electronic exchange of health information that is subject to 42CFR Part 2 using existing technology platforms• 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
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Benefits of Data Standards
The integration of behavioral health and physical health is contingent upon health information exchange
It is critical that health care providers can interpret the information they receive from other providers
Standards for collection and storage of health information are needed for both interpretability and integration of data into the receiving record
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Benefits of Data Standards
The adoption of interoperable data standards can improve patient care and facilitate research• More accurate and consistent data will be
available• Quality measurement• Real time outcome tracking and surveillance• Standard information will allow programs to cross
reference and validate patient information.
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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
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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?
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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 patient’s depression score decrease with treatment)
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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
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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
ADVANCED TOOLS
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BH Treatment Lifecycle
Patient Identification
Brief Intervention or ReferralBrief Patient
Assessment
Patient Treatment
Patient Placement
Full Patient Assessment
Outcome Tracking
Quality Data Reporting
Clinical Decision Support
Patient Education and Engagement
Shared Decision Making
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BH Treatment Lifecycle
Patient Identification
Brief Intervention or ReferralBrief Patient
Assessment
Patient Treatment
Patient Placement
Full Patient Assessment
Outcome Tracking
Quality Data Reporting
Clinical Decision Support
Patient Education and Engagement
Shared Decision Making
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
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BH Treatment Lifecycle
Patient Identification
Brief Intervention or ReferralBrief Patient
Assessment
Patient Treatment
Patient Placement
Full Patient Assessment
Outcome Tracking
Quality Data Reporting
Clinical Decision Support
Patient Education and Engagement
Shared Decision Making
EHRs/PHRs can collect patient reported standard assessments
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.
suicidality) Collect standard data on patient symptoms
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BH Treatment Lifecycle
Patient Identification
Brief Intervention or ReferralBrief Patient
Assessment
Patient Treatment
Patient Placement
Full Patient Assessment
Outcome Tracking
Quality Data Reporting
Clinical Decision Support
Patient Education and Engagement
Shared Decision Making
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 exchange Health Information Exchange tools Referral appointment scheduling Referral management and follow up
tools Care coordination tools
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BH Treatment Lifecycle
Patient Identification
Brief Intervention or ReferralBrief Patient
Assessment
Patient Treatment
Patient Placement
Full Patient Assessment
Outcome Tracking
Quality Data Reporting
Clinical Decision Support
Patient Education and Engagement
Shared Decision Making
Decision support for level of care
Treatment plan is auto-populated and modified by clinician Methods for capturing
standardized data on non-pharmacologic treatments will be needed
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BH Treatment Lifecycle
Patient Identification
Brief Intervention or ReferralBrief Patient
Assessment
Patient Treatment
Patient Placement
Full Patient Assessment
Outcome Tracking
Quality Data Reporting
Clinical Decision Support
Patient Education and Engagement
Shared Decision Making
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 treatment:
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
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BH Treatment Lifecycle
Patient Identification
Brief Intervention or ReferralBrief Patient
Assessment
Patient Treatment
Patient Placement
Full Patient Assessment
Outcome Tracking
Quality Data Reporting
Clinical Decision Support
Patient Education and Engagement
Shared Decision Making
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
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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
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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
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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 GRANTS
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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 underserved
• Examples include Web-based services, smartphones, and behavioral health electronic applications (e-apps).
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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) grantees. To develop infrastructure that supports the exchange of health
information through EHR data systems.
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
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Conclusion
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.
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HAVE QUESTIONS?
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, 2012Scott Weinstein, JD
OCPO Overview
• Chief Privacy Officer position created in HITECH Act
• OCPO’s 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
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SAMHSA, ONC-OCPO, and 42 CFR Part 2
• SAMHSA– Enforces Part 2– Provides Guidance to Providers on Part 2
Compliance
• ONC-OCPO– Working with SAMHSA to explore technologies
that allow exchange of electronic substance abuse clinical information while complying with Part 2
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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
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Data Segmentation for Privacy Initiative
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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
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Provider/Healthcare Organization 1
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.
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Provider/Healthcare Organization 2
Provider/Healthcare Organization 1
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 redisclosure.
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Provider/Healthcare Organization 3
Provider/Healthcare Organization 1
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.
Allergies
Allergies
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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
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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
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Query Health
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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.
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Improve community understanding of patient population health
Questions about disease outbreaks,
prevention activities, health research,
quality measures, etc.
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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
Summary: Query Health Specifications and Standards
Query Health must standardize how queries are asked, how they are returned, and how the information travels between parties.
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Notes:1.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 data2.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 regulation.3.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 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:1.Disclosing Entity: Queries and results will be under the control of the disclosing entity (e.g., manual or automated publish / subscribe model).2.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. 3.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.
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:1.Disclosing Entity: Queries and results will be under the control of the disclosing entity (e.g., manual or automated publish / subscribe model).2.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. 3.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.
Policy Sandbox
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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
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State Health Policy Consortium (SHPC) - Behavioral Health Data
Exchange Consortium
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Purpose
• Pilot the interstate exchange of behavioral health treatment records among treating health care providers using Nationwide Health Information Direct protocols
• Draft Policies and Procedures (P&P) 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
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Participants
• 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
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Workflow Scenarios for Discussion
Workflow #1: Request for info
• Alabama PCP sends referral to Florida Part 2 program
Workflow #3: referral
• At end of patient’s stay, New Mexico provider (who is a Part 2 program and a mental health provider) sends patient summary to patient’s PCP in Kentucky
Workflow #2: Update PCP
Florida Part 2 program requests patient’s records from prior stay at Michigan behavioral health provider facility (a Part 2 program)
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Workflow #1 – Request for Info
HISP HISP
Michigan Part Michigan Part 2 Program2 Program
Florida Part Florida Part 2 Program2 Program
Jane PatientJane Patient
Treatment Treatmen
t
Signs
consent
Send request for records along with patient consent
Receive request for records along with patient consent
Send patient records specified in patient consent
Receive requested patient records
1
2
3
4
5
6
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9
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Workflow #2 – Update PCP
HISP HISP
New Mexico New Mexico Part 2 Program Part 2 Program
& Mental & Mental Health ProviderHealth Provider
Kentucky Kentucky Primary Primary
Care Care ProviderProvider
Jane PatientJane Patient
Treatment
Treatmen
t
Jane submits clarifying
infoSigns consent
Sends visit summary and clarifying info
Receives visit summary and clarifying info
1
2
3
4
5
6 7
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Workflow #3 - Referral
HISPHISP
Alabama Alabama Primary Care Primary Care
ProviderProviderFlorida Part Florida Part 2 Program2 Program
Jane PatientJane Patient
Treatment Future
Treatmen
t
Sends referral
Receives referral
1
2 3 4
5
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State HIE Community of Practice Privacy and Security Workgroup on
42 CFR Part 2
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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 efficiencies.
• 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
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Thank you
Prepared in 2012 by – the Legal Action Center,
under a subcontract fromPartners for Recovery
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