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The Behavioral Health Data
Standards Work Group
. . . . . . . . . .
Navigating the
Behavioral Health Data
Standards Landscape
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September 29, 2005
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I. Overview
The Key Challenge Facing Behavioral Health
A critical issue facing behavioral healthcare—the system for treating mental
health and substance abuse problems—is how best to manage information to
improve patient care and safety while at the same time protecting patient
rights and privacy. Research suggests that the current behavioral health
information infrastructure is used mostly for administrative reporting purposes
and that it is far from ready to use information to improve clinical decision-
making or clinical program planning. There is clearly pressure on the
behavior health field to change. President Bush issued Executive Order 13335
in 2004 that called for the widespread adoption of interoperable electronic
health records (EHR) within 10 years and established the National
Coordinator of Health Information Technology to provide leadership to
achieve this goal. Executive Order 13335’s intent is to improve patient safety
and health care by ensuring that historical and real-time clinical information
follows the patient. The presumption is that the electronic availability of this
information will improve efficiency and service quality by enabling eligible
service providers and consumers to access critical information at any point
and place in time to make better, more informed decisions.
The Executive Order applies to all the components of the health care industry,
including behavioral healthcare. While the Order falls short of mandating the
adoption of interoperable electronic heath care records, it is clear that there
will be tremendous on the entire health care industry to improve its
management of information. If the behavioral health field is to participate in
the nationwide service delivery shift, it will need to improve its use of
information. It will also need to identify mental health and substance abuse
information critical to being included in a common electronic health care
record. Decisions will involve addressing some potentially difficult policy
issues such as: 1) what information that is unique to behavioral heath should
be incorporated into an EHR? 2) should there be time limitations in the EHR
on information that unique to behavioral health, i.e., should there be time
limitations attached to certain behavioral health data elements, e.g., should a
diagnosis of alcoholism be maintained 25 years after sobriety has been
attained?, 3) what opportunities exist for the behavioral health field to
influence the development of EHRs?, 4) what role should behavioral health
consumers and service providers play in actively managing behavioral health
information and other data standards? And 5) how should EHRs address
privacy and confidentiality?
Beyond the specific EHR, there is a broader issue about the ability of the
behavioral health system to accommodate the use of electronic information for
clinical purposes. The field’s high turnover rate, especially in substance
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abuse, low rate of use of information technology, and poor administrative
infrastructure do not bode well for the field’s adoption of EHRs. Some
experts are concerned that pressures to adopt EHRs could result in some
service providers closing or cutting back services simply because they cannot
afford the necessary financial investment. They are also concerned that
providers will no longer be able to provide appropriate evidence-based care if
they do not have interoperable EHRs and should join with other practices to
maintain their treatment capacity. These problems might be averted if the
effort to adopt the EHR creates market forces that favor cost savings,
improvements in the quality of care, and more stability in the field.
The effort to implement EHRs in behavioral health must also accommodate
privacy concerns. Patients face considerable stigma because of their mental
health and substance abuse problems so much so that they sometimes feel
unable to return to a normal life in the community. For example, rather than
celebrating sobriety, a patient often hides it to prevent negative consequences
related to returning to the workforce. This is done to avoid discrimination
against them by insurance, employment, education, housing, and social
services. This is just one of the reasons why privacy concerns are so
important to this population and to behavioral health. These concerns are so
pivotal that 30 years ago Congress saw the need to pass specific legislation to
protect confidentiality of alcohol and drug records.
A second reason for heightened concerns about privacy and confidentiality is
that behavioral health also has the unique distinction of having many of its
referrals come from the criminal justice system. According to recent
information, the criminal justice system is responsible for about 55 percent of
all referrals to substance abuse treatment; it is responsible for XX percent of
referrals for mental health services. No other part of the health care industry
is subject to the influence of law enforcement for patient referrals. This link
to the criminal justice system creates additional information burdens for
behavioral health with regard to patient care and management.
The Need for a National Health Information Infrastructure
The Institute of Medicine and a number of federal agencies are promoting a
national health information infrastructure to provide for safe and efficient
health care. Fulfilling this need is the basis for the Administration’s
Executive Order calling for the establishment of an interoperable EHR within
ten years. HHS has taken a strong leadership role by supporting activities to
promote more understanding of what infrastructure is needed to build a
national health infrastructure to improve patient health, safety, and privacy. It
created the Office of the National Coordinator for Health Information
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Technology (ONCHIT) to provide leadership for the development and
nationwide implementation of an interoperable health information technology
infrastructure to improve the quality and efficiency of health care and the
ability of consumers to manage their care and safety. ONCHIT develops
recommendations for HHS on the development, application, and use of health
information technology and coordinates health information technology
programs. ONCHIT works with both the public and private sectors in its
quest to implement a nationwide interoperable health care information
technology.
In support of the Administration’s Executive Order, HHS is moving forward
with a number of important initiatives:
• In June, 2005, HHS announced the formation of the American Health
Information Community (AHIC) to help the private sector initiate
activities to transition to electronic health records, including common
standards and interoperability. AHIC is to provide input and
recommendations to HHS on how to make health records digital and
interoperable, and assure that the privacy and security of those records
are protected.
• HHS also issued four major requests for proposals (RFPs) to help
implement its health information technology initiatives. These four
initiatives are designed to:
Develop, create prototypes for, and evaluate a process to unify and
harmonize industry-wide health IT standards development,
maintenance and refinements over time.
Develop, create prototypes for, and evaluate a conformance
certification process for health IT, including the infrastructure or
network components through which health IT systems interoperate.
Assess and develop plans to address variations in organization-
level business policies and state laws that affect privacy and
security practices, including those related to HIPAA, which may
pose challenges to interoperable health information exchange.
Develop, and create prototypes for, and evaluate a nationwide
health information network (NHIN) internet architecture for
widespread health information exchange that can be used to test
specialized network functions, security protections and monitoring,
and demonstrate feasibility of scalable models.
These four RFPs will help to shape national public/private sector collaboration
through the AHIC to promote the successful adoption EHRs within 10 years,
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by 2014. It is expected that HHS will announce the awardees at the end of
September, 2005.
The Administration also recently released its Federal Mental Health Action
Agenda, which is designed to improve the nation’s public and private mental
health service delivery system. A keystone of the transformation process will
be the protection and respect of the rights of adults with serious mental
illnesses, children with serious emotional disturbances, and their parents.
There are specific goals that relate to information technology: One goal is to
"Develop a Strategy to Implement Innovative Technology in the Mental
Health Field. SAMHSA will convene a consensus development workgroup to
review the current status of telemedicine, information technology, Internet
technology, and electronic decision support tools in health care; examine the
current status of implementation of these tools in mental health; and prepare
key recommendations for immediate next steps in technology support for
mental health services. Another goal is to “Explore Creation of a Capital
Investment Fund for Technology [by creating] a Capital Investment Fund for
Technology to work with States to design and implement an electronic health
record and information system that incorporates an individualized plan of
care.”
The Behavioral Health Data Standards Work Group
HHS is providing national leadership in the area of behavioral health data
standards. The Substance Abuse and Mental Health Services
Administration’s (SAMHSA) Center for Substance Abuse Treatment is
sponsoring the Behavioral Health Data Standards Work Group (BHDS).
BHDS’s mission is to increase knowledge, understanding, and use of
behavioral health data standards in substance abuse and mental health. It
works to identify opportunities to influence standard-setting activities,
coordinates such efforts with key stakeholders, and apprises interested parties
about behavioral health data standard issues.
BHDS members understand that data standards are critical elements of EHRs
and that behavioral health presents a number of thorny issues that must be
incorporated into the discussion of how best to construct such records.
Workgroup membership includes a mix of individuals representing substance
abuse prevention and treatment and mental health services and the technology
sector who also have expertise in policy; information technology and
technical data standards; HIPAA standards and standard-setting activities;
commercial data standards; performance measurement; privacy and
confidentiality; behavioral health managed care; federal mental health,
substance abuse prevention and treatment data systems; Information
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Technology; and State data system capabilities, and government data
requirements.
BHDS has held two meetings in 2005 to establish the following priorities:
1. Electronic Health Records:
• Identify the essential behavioral health data elements that need to
be a part of an electronic record for substance abuse and mental
health.
• HIPAA and privacy standards in the age of electronic health
records—BHDS wants to develop expertise in this area to ensure
changes in behavioral health accommodate this specialized topic.
• Establish/maintain ongoing liaison with data standard setting
organizations.
2. Prescription drugs. Delineate the different role of prescription drugs in
mental health and substance abuse and determine common standards that
can be developed to support both fields and determine situations in which
separate standards and business processes are will be required for EHRs
and other standards. For instance, ePrescribing impacts the mental health
services more than substance abuse treatment, since MMA covers more
medications used for mental illnesses than for substance abuse. The use of
prescription drugs is different in mental health and substance abuse
treatment. Substance abuse services tend to utilize prescription drugs less
often than mental health. How this difference affects EHRs needs to be
better understood. In addition, BHDS might develop data standards to
support state-level efforts to monitor prescription drug abuse.
3. HCPCS Codes. Continue stakeholder review of current codes and
recommendations for new codes; development of companion guides to
support consistent use of codes; impact of continued use of local codes
4. Performance Measurement and Management. Assure data standards
support recent advancements in performance measurement and
management techniques. For example, it could help to support
SAMHSA’s Data Strategy by ensuring that data standards are developed
to support its National Outcomes Measures (NOMs) and to incorporate
NOMs into nationwide standard setting organizations.
The BHDS is a resource to assist policy and program managers, the
behavioral health field, software vendors who write code for service
providers, and consumers of behavioral health with understanding best how to
improve health care quality while ensuring consumer privacy. Finding the
correct balance between improving services and protecting the consumers of
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such services is not an easy task. Clinicians want as much information as
possible to make effective health care decisions for their patients. Service
provider administrators need certain information for billing and reporting
performance to higher authorities. The overall performance of a clinic
represents information that might find its way into state and federal reports
describing their performance effectiveness (e.g., the National Outcomes
Monitoring System). On the other hand, consumers may want to restrict
information to protect them from potential discrimination and other legal
manifestation created by the stigma of their particular health issues. The
BHDS will work to ensure that its efforts will ensure that patient and provider
health, safety, and privacy concerns are addressed.
HHS is also providing leadership in the area of behavioral health informatics.
SAMHSA is sponsoring, along with the Software and Technology Vendors’
Association (SATVA), a national summit on “Defining a Strategy for
Behavioral Health Information Management and Its Role within the National
Health Information Infrastructure.” This summit—to be held on September
29-30, 2005—is an invitational, working summit of mental health and
substance abuse treatment and prevention leaders representing a broad range
of constituencies. It reflects a public/private partnership to identify and
address problems that might otherwise impede the field’s progress toward the
successful transformation of information systems in behavioral health.
What is an Electronic Health Record?
The Institute of Medicine formally defines an electronic Health Record (EHR)
as a system that encompasses“(1) longitudinal collection of electronic health
information for and about persons, (2) electronic access to person- and
population-level information by authorized users, (3) provision of knowledge
and decision support systems, and (4) support for efficient processes for health
care delivery.” More simply put, an EHR is a digital collection of
longitudinal information describing a patient’s medical history. It would
generally include information such as diagnosed medical conditions,
prescribed medications, vital signs, immunizations, lab results, and personal
characteristics like age and weight.
The EHR may also be viewed as the master record or data base of information
from which other records or reports may be generated. For example, in the
case of behavioral health, information on outcomes may be rolled up at the
clinic level to report to federal agencies about national performance outcomes.
Or, clinics themselves may want to use these records to monitor staff
performance for purposes of performance management. Patients themselves
may want to create records that contain data elements derived from their case
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histories for purposes of ensuring their safety and safety. For example, a
person may want some of their information stored in an EHR stored separately
in a format that they have available to them as a personal health record (PHR).
An EHR and a PHR is not the same thing. An EHR contains the information
about a patient’s health that is compiled and maintained by healthcare
providers. A PHR contains information about your health that is derived from
the HER, but is compiled by the patient. Because it is less complete than an
EHR, this means that it may not contain all the information that a clinician
might find desirable in making clinical decisions affecting patient treatment.
The behavioral health field is making progress in defining the kind of
information that might be incorporated into an EHR, but more work remains.
Service providers might want to include information related to patient
assessments at various points in their care, information about changes in the
diagnosed underlying condition at intake and discharge, and other information
important to clinicians so they can provide quality care. Patients might want
to include information about their treatment, particularly as it pertains to drug
use and prescription medications. This would seem to be the easy part. What
is difficult for a common consensus is the treatment of information about the
underlying source of referral for services (e.g., a criminal justice referral), the
social context surrounding their problems, access to information by third
parties, and so forth. Clinicians might argue that this information is important
for their work, but consumers of behavioral health services might feel quite
differently. They most likely will want to limit access to such information in
order that they can participate freely and without discrimination back in their
communities.
Achieving the widespread adoption of the EHR by 2014 will be no small feat
for behavioral health. There is no doubt that the development of an EHR can
improve patient care and safety. There is also no doubt that consumers of
behavioral health are concerned that information contained in the EHR might
interfere with their chances of achieving a life in the community.
What are Data Standards?
The federal government and the private sector are working together to develop
data standards to improve patient safety and heath care while protecting their
privacy. So, what do we mean by data standards and how does this concept
apply to the field of behavioral health? At its heart, data standards refer to
methodologies or rules for collecting, exchanging, storing, and retrieving data
elements associated with health care. According to the Institute of Medicine,
data standardization involves determining the information content to be
collected and available for exchange; establishing formats to electronically
encode specific data elements; establishing the medical terms and concepts to
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describe, classify, and code data elements; and establishing protocols to
electronically represent information. For behavioral health, a significant
challenge is how to integrate narrative information, which tends to be the most
important information for clinicians. Narrative information is not easily
classified into neat, specific data elements that can improve patient care and
safety—and perhaps this should not be a goal for behavioral health. Instead,
the real challenge is to develop standards to get narrative information in
electronic form that is linked to the treatment plan, the billing system,
administrative reporting systems, and so forth. The point is to design a system
that integrates into the day-to-day clinical activities peculiar to behavior
health.
Data standards must also be developed to enable the evaluation of the
performance of behavioral health. In this regard, substantial progress has
already occurred from SAMHSA’s NOMs effort. Working with the States,
SAMHSA identified ten outcome measures that reflect real-life outcomes for
people who are striving to attain and sustain recovery, build resilience, and
work, live, and participate fully in their communities.
• One measure is abstinence from drug use and alcohol abuse or
decreased symptoms of mental illness with improved functioning.
• Four measures focus on resilience and sustaining recovery. These
include getting and keeping a job or enrolling and staying in school;
decreased involvement with the criminal justice system; securing a
safe, decent, and stable place to live; and social connectedness to and
support from others in the community such as family, friends, co-
workers, and classmates.
• Two measures track available services and services provided by
treatment. One measure is increased access to services for both mental
health and substance abuse. Another is increased retention in services
for substance abuse or decreased inpatient hospitalizations for mental
health treatment.
• The final three measures examine the quality of services provided.
These include client perception of care, cost-effectiveness, and use of
evidenced-based practices in treatment.
Behavioral health’s challenge is how best to obtain this information from
service providers without burdening day-to-day activities. Standards for
extracting for the transition to an EHR from narrative data, the clinician, or
the patient must be considered and developed.
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What are Privacy Protections?
The federal law and regulations that protect the confidentiality of drug and
alcohol information were first passed in the early 1970's in order to afford
sufficient privacy protections so that persons in need of alcohol and drug
treatment would feel comfortable enough to come forward for care without
fear of being arrested or losing their jobs or other necessities of life. For the
almost three decades since the Federal confidentiality regulations (42 CFR
Part 2 or Part 2) were issued, confidentiality has been a cornerstone practice
for substance abuse treatment programs across the country. While much time
has passed since the law and regulations were enacted, the stigma surrounding
drug and alcohol addiction still remains, and thus these protections are as
applicable and necessary today as they were thirty years ago.
Part 2 protects all information about any person who has applied for or been
given diagnosis or treatment for alcohol or drug abuse at a federally assisted
program. Part 2 regulations apply to substance abuse treatment programs (an
individual or entity that provides alcohol or drug abuse diagnosis, treatment or
referral.) that receive federal assistance. Part 2 protects all information about
any person who has applied for or been given diagnosis or treatment for
alcohol or drug abuse at a federally assisted program.
Congress required HHS to issue patient privacy protections as part of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA). HHS
promulgated privacy standards in 2003 (the Privacy Rule) that provide
patients with access to their medical records and more control over how their
personal health information is used and disclosed. The Privacy Rule
represents a uniform, federal floor of privacy protections for consumers across
the country. State laws providing additional protections to consumers are not
affected by this new rule.
Information is subject to the Privacy Rule if it is individually identifiable
information created, received, or maintained by a health care provider. A
health care provider is defined to include a person or organization that
furnishes, bills or is paid for health care in the normal course of business.
This, of course, includes substance abuse treatment programs. Information is
subject to the Privacy Rule if it is individually identifiable information
created, received, or maintained by the health care provider.
The Privacy Rule limits the ways that covered entities, such as health plans,
health care clearinghouses and healthcare providers (such as pharmacies and
hospitals), and other covered entities can use patients' personal protected
health information. The regulations protect medical records and other
individually identifiable health information, whether it is on paper, in
computers or communicated orally.
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Key provisions of the Privacy Rule include:
• Individual authorization for disclosure of protected health information
except for treatment, payment and health care operations. Access To
Medical Records—Patients generally should be able to see and obtain
copies of their medical records and request corrections if they identify
errors and mistakes.
• Notice of Privacy Practices—covered health plans, doctors and other
health care providers must provide a notice to their patients how they
may use personal medical information and explain their rights under
the new privacy regulation.
• Limits on Use of Personal Medical Information—the privacy rule sets
limits on how health plans and covered providers may use individually
identifiable health information. The rule does not restrict the ability of
doctors, nurses and other providers to share information they need to
treat patients. Generally, however, personal health information
generally may not be used for purposes not related to health care.
• Prohibition on Marketing—the privacy rule restricts the use of patient
information for marketing purposes.
• Stronger State Laws—the federal privacy standards do not affect state
laws that provide additional privacy protections for patients.
• Confidential communications—Under the privacy rule, patients can
request that their doctors, health plans and other covered entities take
reasonable steps to ensure that their communications with the patient
are confidential.
• Complaints—Consumers may file a formal complaint regarding the
privacy practices of a covered health plan or provider.
In several important respects, the Part 2 provides greater privacy than the
Privacy Rule (e.g., when it comes to disclosing information to criminal justice
system and for treatment, payment and health operations). Substance abuse
treatment programs must comply with both rules. Generally, this will mean
that they will continue to follow Part 2’s general rule and not disclose
information unless they can obtain consent or point to an exception to that rule
that specifically permits the disclosure. Programs must then make sure that the
disclosure is also permissible under the Privacy Rule.
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Efforts to promote the widespread adoption of EHRs must take account of
privacy and confidentiality. It is assumed that behavioral health records will
be a part of the EHR and that confidentiality and privacy requirements will
continue to exist. However, what is not clear is whether patients can opt out
of their records being a part of the system. If this is the case, then there
would need to be a careful design of the system to ensure the privacy
requirements are met.
What is the State of the Behavioral health Industry?
When it comes to the issue of using electronic information to improve health
care and address privacy concerns, there is evidence that the state of the
behavioral health field is not good. The behavioral health field provides
specialty treatment programs that are mostly publicly funded and regulated by
the states. Much of the public funding comes from the federal government.
In the case of substance abuse treatment, well over half of the public funds
come from a single source—the Substance Abuse Treatment and Prevention
Block Grant. Mental health services also have a similar block grant, but it
provides only about three percent to five percent of total public expenditures
for mental health services. Programs like Medicaid provide a much more
significant share of public spending for mental health services. One could
imagine that the public funding nature of behavioral health would mean that
national efforts to improve information management could more easily be
promoted through rules or regulations. However, public funding is targeted
for service provision, making the funds unavailable to build the infrastructure
that is required for electronic information management.
While many service providers use electronic records to manage services and
patient information, its use is not consistent across the health care industry nor
is information in it standardized. There are even more serious problems that
could impede the adoption of EHRs.
• Most substance abuse treatment programs lack a full-time physician or
nurse and while many programs use computers for financial
management, but most do not use them for clinical purposes.
• About one sixth of substance abuse programs that were supposedly in
operation had in fact closed during the previous year or stopped
providing addiction treatment; all of the programs were characterized
by a high turnover rate.
• Substance abuse treatment programs have data collection systems and
have dedicated clinical staff to satisfy administrative requirements,
however almost none of the programs had data systems that could
support clinical decision-making.
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What is not clear is the role market forces will play in national efforts to
promote the adoption of interoperable electronic health records and to
introduce more stability in the behavioral health field. On the one hand, it is
possible that market forces will play a small role because of the large role
played by public funding in behavioral health. On the other hand, many
behavioral health software vendors have taken the lead over the past several
years not only in developing viable EHR solutions but in developing strategies
to successfully and reasonably rapidly deploy EHR to agencies. There are now
dozens of proven software options available to an agency as many vendors
have already successfully implemented EHR systems in the majority of their
customers.
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II. Setting Data Standards
Standard Setting Organizations (SSOs)
The design, development, and implementation of behavioral health data
standards involves both the government and private sector organizations that
set standards for the interchange of clinical information and administrative
information for both electronic and paper recordkeeping. Our primary interest
here is with data standards for electronic health records, but standards need to
be developed in other areas related to interoperability and transportability.
This is addressed in more detail in section III. One thing is for certain:
Executive Order 13335’s goal of promoting the widespread use of electronic
records means more pressure for it to adopt electronic record keeping.
The primary means for developing data standards in behavioral health is
through a consensus-based process. Standard setting organizations (SSOs)
are the traditional means to standard setting. SSOs are organizations
accredited by the American National Standards Institute (ANSI). ANSI was
established in 1918 and functions, among other things, as an accreditor of
SSO through its Accreeited Standards Committee (ASC). ANSI does not
provide quality control for data standards that it accredits, but does certify that
the process that led to the creation of a data standard satisfied certain criteria
reflecting a consensus-based process. Out of the more than 200
organizations accredited by ANSI, four SSOs have been accredited in
behavioral health:
• Health Level 7 (HL7)— HL7 is a volunteer organization. Its
members—providers, vendors, consultants, government groups and
others who have an interest in the development and advancement of
clinical standards for healthcare—develop the standards
• Accredited Standards Committee (X12)—X12, a membership based
not-for-profit organization, that is responsible for developing health
care-related electronic data interchange standards for administrative
and business transactions,
• American Dental Association’s Dental Content Committee (DeCC)—
The DeCC creates and promotes standards for all standards related to
dentistry.
• National Council for Prescription Drug Programs (NCPDP)—The
NCPDP creates and promotes standards for the transfer of data to and
from the pharmacy services sector of the healthcare industry.
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In order for these and other SSO’s to maintain their ANSI accreditation, they
are required to consistently adhere to a set of requirements that govern the
consensus development process. ANSI certifies that SSOs develop standards
in a fair, accessible, and open environment. This requirement is designed to
protect the public interest.
Designated Standard Maintenance Organizations (DSMOs)
The Health Insurance Portability and Accountability Act (HIPAA) required
the Secretary of HHS to adopt standards for health care transactions to enable
the electronic exchange of health information. It also gave the Secretary the
authority to establish a new category of organization to maintain data
standards approved by the secretary. These organizations—many of which
have existed long before the passage of HIPAA—are known as Designated
Standard Maintenance Organizations (DSMOs). The Secretary of HHS has
designated the following six organizations under HIPAA as DSMOs [insert
figure]:
• The four standard setting organizations (HL7, X12, DeCC, and
NCPDP, described in the previous section),
• The National Uniform Billing Committee (NUBC)—the NUBC was
formed to develop a single billing form and standard data set that
could be used nationwide by institutional providers and payers for
handling health care claims, and
• The National Uniform Claim Committee (NCC)—the NUCC was
created to develop a standardized dataset for use by the non-
institutionalized health care community to transmit claim and
encounter information to and from all third-party payers.
DSMOs play an important role in helping the Secretary meet HIPAA
requirements with regard to the adoption of standards. Under HIPAA, the
Secretary of HHS has three options for adopting standards, each requiring
DSMO participation:
• The Secretary of HHS may adopt a standard that is developed by a
SSO. The SSO is one that is accredited by ANSI and has consulted
with the relevant DSMO (the four SSOs--X12, HL7, ASC, ADA—
and the NUCC, NUBC) and the Workgroup for Electronic Data
Exchange (WEDI).
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• The Secretary may adopt a standard other than one developed by a
SSO if the standard is a cost-saving one for health care plans or
providers, is promulgated through negotiated rulemaking procedures,
and if the secretary consults with the DSMOs and WEDI.
• The Secretary may rely on the National Committee on Vital and
Health Statistics if there is need for a standard so long as the Secretary
consults with the DSMOs and WEDI. (NCVHS was established in
1949 as a federal advisory committee to HHS on health statistics and
comprised of members from the private sector. HIPAA expanded its
advisory role to include developing data standards for administrative
simplification and to ensure the privacy and security of health care
information.)
Another way to view the SSOs is in terms of their primary area of expertise.
X12 and HL7 focus on electronic transactions. These two organizations differ
though in that HL7 is primary focused with clinical information whereas X12
is concerned more with administrative and financial information.
The NUBC and NUCC tend to focus on paper-based transactions. The NUBC
concentrates on billing and the NUCC concentrates of claims. Some rules of
thumb to help remember the distinctions:
• If it has a number in its name (i.e., X12 and HL7), it is concerned with
electronic information.
• If it mentions claims or billing in its name (i.e., NUBC and NUCC), it
is principally focused on paper transactions.
It is also the case that all of the SSOs are DSMOs, but not all DSMOs are
SSOs. The four SSOs (HL7, X12, NCPDP, and DeCC) are DSMOs. Only
two DSMOs are not SSOs (NUCC and the NUBC).
Adequacy of Behavioral Health Representation on SSOs
A challenge facing behavioral health is how best to represent its interests
within these SSOs. Each organization functions by establishing specialized
committees to develop standards. HL7, for example has committees
addressing areas such as the electronic health record, clinical decision support,
and medical records/information management. X12 has committees that focus
on business models, improving communication to conduct the business of
government, and processes related in insurance business practices. Table X
presents the committees operating under HL7 and X12.
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It is apparent from the information presented in the Table that there is some
overlap in the standards being developed by the SSOs. It is also apparent
from the table that no standard setting organization has a committee devoted
to behavioral health issues. This should not be viewed as a criticism of SSOs.
It more likely reflects the collective decision by the SSOs membership to
organize work around issues of administration (e.g., accounting, security)
services (e.g., clinical laboratory, patient information), and information
management and exchange (e.g., electronic health records, data interchange).
Behavioral health issues related to clinical care, administration, and privacy
will arise in multiple committees sponsored by the SSOs. It is perhaps fair to
say that, because participation in SSOs is voluntary, any perceived inadequacy
of representation of behavioral health issues lies at the doorstep of the
behavioral health field.
So, how does behavioral health promote its interests in standard setting? By
joining these organizations to promote and represent its interests and needs of
the industry. Given Administration’s interest and effort to promote the
widespread adoption of EHRs mean that SSOs focused on electronic
transactions (HL7 and X12) should receive priority attention from the
behavioral health field. HL7 seems to have the most immediate relevancy
because of its focus on clinical and administrative matters.
Healthcare Common Procedure Code Setting Standards
Health care insurers process billion claims each year. For them to ensure that
these claims are processed in a consistent manner, standardized coding
systems are essential. The Healthcare Common Procedure Code Set (HCPCS)
is one of the standard code sets used for this purpose. The HCPCS is divided
into two principal subsystems, referred to as level I and level II of the HCPCS.
Level I of the HCPCS is comprised of CPT (Current Procedural
Terminology)—a uniform coding system consisting of descriptive terms and
identifying codes that are used primarily to identify medical services and
procedures. Level II of the HCPCS is a standardized coding system that is
used primarily to identify products, supplies, and services not included in the
CPT codes, such as ambulance services and durable medical equipment,
prosthetics, orthotics, and supplies (DMEPOS) when used outside a
physician's office.
With respect to behavioral health HCPCS code setting standards, two national
organizations—the National Association of State Alcohol Drug Abuse
Directors (NASADAD) and the National Association of State Mental Health
Directors (NASMHPD)—led the national standard service code development
effort to meet HIPAA electronic transaction and code set requirements. In
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addition, related behavioral health organizations such as AMBHA supported
this effort and SAMHSA played an important role as coordinator.
NASADAD led the effort to develop substance abuse procedure codes,
NASMHPD led a similar effort to develop the mental health procedure codes,
and they worked together to develop the behavioral health procedure and
modifier codes.
Both organizations worked with their members and used a consensus
development approach to identify and define needed standard codes that
matched services provided in their respective fields across the nation. Code
packages that included requests for many individual service codes were
prepared and submitted to CMS for review in several individual and joint
submissions. CMS reviewed the code requests during its review cycles and
provided feedback on individual codes. The two organizations made revisions,
as necessary, and resubmitted a final joint code package. Most of the codes
requested were approved, the HCPCS codes were approved in 2001, 2002,
and 2003, and met the HIPAA compliance dates.
The HCPCS codes are being used successfully today. However, NASADAD
and NASMHPD need to continue their involvement by working with BHDS
and other interested parties to review the HCPCS codes on an ongoing basis.
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III. Options to Support the Adoption of
EHRs in Behavioral Health
Transitioning to Electronic Health Records
Getting the behavioral healthcare industry to adopt electronic records within
this decade requires will require a concerted effort. If this transition is to
occur in a smooth way, it will require a structured process full of incentives.
This is not a clarion call for government subsidies as the solution. Instead,
transition must be motivated from within the field itself. This will occur if the
field expects three things from a transition to electronic records: 1) financial
benefits, 2) patient care and safety benefits, and 3) oversight benefits.
• Financial benefits are those cost savings resulting from improved
billing, clinical practices, and administrative savings related to
efficiency improvements. In short, the transition must not contribute
to a provider’s overhead, otherwise it is doomed to fail.
• Patient care and safety benefits are those that result from the
confluence of electronic information to improve the quality of care and
to protect a patient from internal breakdown in clinical or
administrative practices.
• Oversight benefits are those that result from improvements in
reporting to government agencies, insurance companies, and other
third parties will some regulatory oversight of behavioral health.
For the transition to be complete, it requires that the behavioral health field
develop standards in other areas. The two key areas relate to transportability
and interoperability. Transportability refers to the need to develop a protocol
to transfer records—including data elements and the narrative portion of the
record. Interoperability refers to the ability of software and hardware on
different machines from different vendors to share data.
Linking to the Behavioral Health Process
Behavioral heath uses a medical model to diagnose a patient’s problem and
uses the treatment plan as the underlying tool for effective service provision.
Clinical practices, organized around the medical model, define the physician's
task as diagnosing diseases, to discovering their causes and symptoms, and
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designing treatments. The treatments are aimed at eliminating or minimizing
the symptoms of the disease, or the cause of the disease, or the disease itself.
In behavioral, the medical model does not affect substance abuse and mental
health treatment in the same manner. Substance abuse treatment has few
diagnoses and relies on a treatment plan to guide the day-to-day clinical
activities. Substance abuse certainly has a rich variety of patients with
complex stories about their problems, but diagnoses tend to fall into the two
categories of dependence or abuse. Mental health is much more attuned to the
medical model as it possesses a rich set of diagnoses and treatments for those
diagnoses.
A good electronic record in behavioral health must accommodate narrative
information using standardized protocols. This is because narrative
information is much more important in behavioral health than it is for the rest
of the health care industry. Clinicians think in terms of stories—narrative data
is collected as part of clinical activities related to an assessment and the
treatment plan. This means that that narrative information must form the
basic building block in the behavioral healthcare electronic record, but in a
way that permits administrators and others to extract certain specific
information about process and outcomes. The challenge for behavioral health
is how to develop a standard to transport this information.
A good electronic behavioral health record must also accommodate data
elements related to process and outcomes. This is because the clinic’s
administration thinks in terms of reporting requirements to its funders. For
example, the clinic may need to report certain outcome data at a client’s
discharge to a government agency.
Finally, behavioral healthcare processes rely on structured assessments to
formulate a treatment plan for the patient. No common standardized
assessment tool or treatment plan exists, nor should they. Structured
assessments exist for many different populations (e.g., children versus adults)
and settings (jail versus outpatient treatment) and structured treatment plans
are formulated to meet each patient’s unique history and circumstance.
Patient information related to assessment and treatment planning is a critical
to successful behavioral health practices. Again, the challenge for behavioral
health is how best to transport this information.
EHR Lessons Learned
Many providers of behavioral health have developed electronic information
management systems to support their activities. Whether any have developed
pure electronic EHRs is debatable. Anecdotal evidence suggests that
electronic systems are born out of a need to satisfy an administrative
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requirement such as billing or special reporting to a funder. The extent to
which such systems inform clinical practices and patient care is even less
known.
It is known that software vendors have played a leadership role in moving the
behavioral health field toward an EHR. SAVTA reports, for example, that it
is now almost a competitive necessity for behavioral health software vendors
to offer a successful EHR solution. The will includes the three areas of
transportability, interoperability, and data standards.
The National Council for Community Behavioral Healthcare (NCCBH),
which participates in the BHDS group, recently queried its membership for
its experience with regard to lessons learned from efforts to develop EHRs.
The replies tended formed advice in two broad areas: 1) Be sure that the EHR
supports the business practices that work for your organization and not that
you have to adapt your business practices to the requirements of the software,
and 2) Be sure that you have access to the code so that you can make changes
quickly because nothing ever stays the same for very long.
SAVTA software vendors also report lessons learned from their experience
with EHRs, such as:
• The intake process must accommodate patient needs including their
treatment history. EHRs should include the following types of
information:
Demographic,
diagnosis,
prior treatment
reasons for treatment,
effectiveness of prior treatment
medication history
• EHRs must link to treatment plans. This involves including key
information in the plans such as:
Standardized or predefined problems, goals, objectives, &
interventions (or their like)
Reconciliation of treatment plan with any authorizations
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Some method to compare similar Treatment Plans for
effectiveness of treatment (Outcome Measures and Evidence
Based Treatment)
• A notification system to assure compliance with treatment protocols
• Online methods to record progress notes linked to interventions and
objectives
• A record of coverage available and authorized by all third party payers
(primarily for Mental Health)
• Integration with billing system (especially for Mental Health)
• Ability to concurrently support all clinical environments, such as;
Outpatient
Residential
23 hour
Inpatient
Case Management
Outreach
Day Treatment
Crisis
Community (school, jail, home, etc.)
According to SAVTA, fatal design flaws include anything that increases work
for the line staff above and beyond day-to-day clinical practices and tends to
include any situation requiring double entry of data, the imposition in the
software of a process that does not reflect agency process, or any situation
where the same process must be managed repeatedly. The point is that the
successful transition to an EHR requires it to support day-to-day clinical
activities and not add to overhead either in costs or reporting.
Navigating the Road Ahead
The successful, widespread adoption of EHRs in behavioral health requires
that a number of hurdles be overcome related to the stability of the behavioral
health industry, the nature clinical practices and the information required to
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provide quality care, the transportability and interoperability of information,
and the creation of incentives. Behavioral health—like all of the health care
industry—must realize improvements in operational efficiency (i.e., cost
savings per unit of service) and performance effectiveness (i.e., improvements
in the quality of care demonstrated in specific outcomes) for a successful
transition.
Both the public and private sectors must work together to facilitate this
transition. At the national level, there is a need to identify the educational
information and other types of technical assistance required to help move this
agenda forward. There is also the need to ensure the adequate representation
of the behavioral health industry and understanding of the unique needs of
behavioral health within the standard setting environment to assure successful
development and implementation of solutions. There is also the need to
identify the mechanisms to sustain progress and widespread adoption of
EHRs.
Substantial progress has already occurred with respect to the identification of
standard measures for monitoring the quality of behavioral health.
SAMHSA’s NOMs, for example, provides the foundation for relevant
performance measurement—behavioral health must determine how best to
collect this information from the narrative-based behavioral health record.
Another hurdle is to determine how best to improve representation of
behavioral health within the standard setting environment. This will require
an assessment of current activities and a plan of action to better influence
these activities.
Yet another hurdle pertains to the tradeoff between patient privacy and
confidentiality concerns and patient care and safety. Behavioral health
providers and patients will need more understanding of the potential impact of
EHRs on patient privacy and health. Then they can determine how best to
manage information to enable clinicians and their patients to achieve and
sustain recovery without jeopardizing anyone’s ability to fully live in their
communities. Regardless of whatever system is established for EHR's, it will
likely at a minimum have to address the strictures of the federal
confidentiality law.
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