Meeting Minutes Policy Workgroup 10/7/15 | 10:00 – 12:00 pm | HCPF, 303 E. 17th, Room 11B Type of meeting

Workgroup Meeting

Chair

Jenifer Jessup

Members in Attendance: Brian Turner; Carol Bruce-Fritz; Shane Mofford; Aditi Ramaswami; Chet Seward; Mark Johnson; Lou Irwin;

Co-Chair

Brian Turner

Phone: Ellen Jensby; Chris Habgood; Lisa VanRaemonck

SIM Representative

Tara Smith; Sydney Oelerich

Guests: Alison Laevey; Emily Haller; Don Sutton; Caitlin Everett; Catherine Strode; Jennifer Miles; Alyssa Auck

Discussion Items: Presentation on Behavioral Health Information Exchange Toria Thompson, the Behavioral Health Information Exchange Coordinator with the Colorado Regional Health Information Organization (CORHIO), presented on the legal and regulatory issues surrounding the exchange of behavioral health information 

Background information – what is CORHIO o Every state in the country has at least one health information organization; organizations run health information exchanges (HIEs) in state o In Colorado, there are two:  CORHIO is responsible for the Front Range, North, and South  Quality Health Network (QHN) covers the West Slope o Main purpose of HIE - to enable exchange of health information o Information that COHRIO has:  In business for 3.5-4 years  Right now have the data from 48 hospitals, 11 more underway  Represent 93% of bed  In exchange under a master patient index; every time a visit is reported, compare demographic data on 12 data points  About 4 million unique patients o Who uses data:  126 LTC facilities  2600+ office-based providers – 7,200+ total users o Number of products:  Patient Care 360 – portal for providers, staff that support providers (i.e., front desk, billing); search on patient, find information on labs, radiology, transcribed notes  Results delivery – push results into EHRs of provider organizations; in hospital, ask who providers are; that information gets uploaded into system, CORHIO then pushes to participating provider organizations  Working to bring ambulatory data through ONC grant; working with 7,200 physicians who right now are just pulling data out to get their data  Also working to get BH data in; the 360 view should eventually include hospital, ambulatory, and BH information

The Project described was supported by Funding Opportunity Number CMS -1G1-14-001 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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Toria’s position to help with behavioral health data piece; records more protected by regulations; funded by Rose Participation in CORHIO is voluntary – paid for by participants that are providing data  Hospitals pay to interface with CORHIO; also pay an annual fee to have ongoing relationship  Still see cost savings because they don’t have to constantly pull one-off reports; providers can pull at will  For providers, have grant (ONC - $2.5 million) to help pay interface costs; will then charge an annual fee, much less than what charge hospitals to be affordable  CORHIO used to be the state appointed EHR Agency COHRIO gets data that the hospital sends – some have satellite sites in Kansas; may include records for out of state patients, not just Colorado residents Is there a network with other states?  Federal government recently created policy called “Healthy Way Exchange” – how one HIE can exchange data with another HIE; currently in process of connecting with Kansas  Also working on cross-HIE partnership with QHN; then branch out to others A non-for-profit; used to be the state designated entity for HIE  When federal funds flowed through state, came to COHRIO, which dispersed  Has changed, now a separate body will be SDE, and COHRIO will be a non-profit COHRIO has separate MPI than QHN; working to interface so can share a common MPI  One of things SIM will be tackling is how to personally identify patients we will be tracking  CIVHC has own MPI; right now have at least 3 MPIs (CIVHC, COHRIO, QHN)  Notion of one single MPI for state probably not doable; but MPI technologies can talk to each other, reconcile with each other  One of HIT WG goals – purchase MPI technology Hospitals either participate in COHRIO or QHN, no overlap  Will eventually have a pass-through; so will be able to see each other’s data  QHN been in business for 10-12 years; much more data and penetration  Will be close to 100% of hospitals

Regulatory Landscape: o In the context of SIM:  In HIT committee, still working out what data SIM is going to collect  Providers participating in SIM will be contributing data to some kind of a centralized repository; will have some level of a dashboard to report back to those practices how they are doing across 18 measures; along with state-level metrics  What is the data these practices are going to send?  Can either report: Y/N an A1C was collected on a diabetic (i.e., A1C level in a person with a diabetes diagnosis) -OR- may report the value (i.e., what the A1C level was)  Screen for substance use disorder: will be Y/N, or the exact results (10/10)  Whether or not they are sending a Y/N or an actual value will trigger whether have to deal with confidentiality laws  First milestone in Feb 1; to set up a system where practices can send patient-identifying data by that time a big lift  Initially may ask practices to report non-identified data; i.e., out of 100 patients, I screened 50  In this instance, no patient identifying information, so no confidentiality concerns  Eventually WILL be sending patient-identified results  Does the system that SIM HIT group develops need to involve patient consent  Until this point, COHRIO has been a collector and pass-through for data, not an analyzer; this represents a change in function

The Project described was supported by Funding Opportunity Number CMS -1G1-14-001 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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COHRIO and QHN want to participate in SIM in helping with data extraction and transmission (the arrows)  COHRIO and QHN not interested in providing an analytic tool that would be a dashboard (RFP not out yet, haven’t responded; expect will respond to how would collect)  Who is going to run and manage the dashboard a different issue; have had conversations with other health IT organizations – CIVHC, CCMCN  Might be that group of organizations bid on providing the whole package, and contract within it; will be determined once RFP is out, expected in 30-60 days  Collection/aggregation of data will be integrated and analyzed along with claims data Out of all the measure that SIM will track, the SUD screening of most concern; the rest of measures, even with mental health, will be okay as long as following HIPAA  When substance abuse involved, more sensitive  If planning on collecting patient-identified, SUD screening results on Feb 1, then confidentiality/consent EXTREMELY IMPORTANT  If practices unable to do so, or technology not in place to collect, then have more time to work on Key federal laws:  42 CFR Part 2 – a federal law enacted in 1970s to encourage people to seek treatment without fear of arrest/prosecution, lost custody, lost jobs, etc.  HIPAA – can share records for treatment if covered entity or business associate  If covered by both, must go with most restrictive (42 CFR)  Definitions key – “program”, “federally assisted”  SBIRT – Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidencebased practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs; may or may not be covered under 42 CFR depending on who administers  Information sharing can be limited if patients are treated by BH Specialists because BH specialists are protected by 42 CFR  Aggregate data can be shared, but not results or client specific data that indicates an issue, and the person administering the screening is identified as a BH specialist Implications for SIM  If information collected in way that is it under 42 CRF, then could not share without patient consent  When report to repository, could not report back out without consent  Even if consent obtained, cannot re-disclose; only consent to one disclosure; cannot be sent to anyone else – prohibition goes along with the disclosure  Can report out as aggregate data without an issue  Issue is: SIM dashboard now contains information that is protected by 42 CFR, that can’t be disclosed without consent  If consent to give data to SIM, SIM could not re-disclose in a patient identifying way (if wanted to); i.e., could not report back down to practice  KEY QUESTION - Does some level of consent, some way of gathering patient consent, need to live at SIM level  In general, if practices set up in way that make sure those doing screening are not covered by 42 CFR, then don’t have to worry about consent  Wouldn’t be the case for a mental health center - in general 100% of their data would have to be shared with consent; mental health clinics in general are prohibited from sharing a great deal of their data due to 42 CFR; depending on the type of data, the type of provider, and the type of condition, patient information could be protected under the law.

The Project described was supported by Funding Opportunity Number CMS -1G1-14-001 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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Congress (Health, Education, Labor & Pension Committee) is meeting in October to hear an argument against privacy when it impacts patient safety Just because we can share through consent, doesn’t mean we always should; goal should not be to share everything – real concerns about privacy  Next spring, COHRIO planning to launch a patient portal where they can give consent, then revoke  As patient, I may not know if provider is covered by 42 CFR or not; may not know whether data will be disclosed  An emergency exception does exist, for patient safety Issue for SIM: does SIM need to invest in some sort of consent model  At IT level, can we do what we need to do without investing in a consent model  Likely that physical health providers will be able to share without triggering consent  Just because we can, do we need to?  In some instances, still may need to get consent How community mental health centers (CMHC) are currently interpreting 42 CFR 1. Entire CMHC is covered by 42 CFR – nothing can be shared 2. Multi-use facility: program data protected 3. Multi-use facility: SUD identifying data is protected CMHC who are part of SIM trigger and follow most restrictive interpretation will run into issues with MULTIPLE SIM clinical measures – i.e., depression screening, maternal depression, anxiety

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Comments from Workgroup: o Chris Habgood: When it comes from regulation of 42 CFR, states can provide guidance, but information must really come from federal government; but better to get interpretation directly from the federal government, the interpretation that matters; in addition, there are parameters, exemptions that are very nuanced and can be explored (i.e., qualified service organizational agreements – other states have used to develop entire networks for sharing information); state has a unique role when it comes to protected information, in that states allowed through auditing function and for research to collect information and have that information readily available; don’t re-disclose, but can use for reporting o Marijo Rymer: Developmental and Intellectual Disabilities - how do the laws and privacy barriers effect this group? They have a difficult time getting adequate care because of co-morbid issues and the requirement for diagnosis before treatment can take place

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Right now consent managed mostly on paper; COHRIO trying to create cloud-based system; should SIM be looking at the same thing?

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If someone gets referred out for treatment to a CMHC, would want to have those records; SIM is not creating a comprehensive clinical record where that would be shared; when sharing records, definitely talking about consent o CORHIO and QHN are working on creating a vehicle for information sharing between the PC practices and the MHPs. It is part of CORHIO’s mission and QHN’s Mission o Currently not written into SIM – potentially address as a long-term concern

Discussion of Policy Categories (“Buckets”) and Priorities  The Policy Buckets we came up with at the last meetings were posted on Basecamp; still have work to do in identifying and sorting out priorities – need to develop “muscle memory” by going through the paces on certain issues  Four buckets identified would be “categories” for organizing issues/ideas that other Workgroups, stakeholders contribute or that group generates o Within buckets, sort into short and long term issues o Continue to identify education priorities, schedule learning sessions – have at each meeting

The Project described was supported by Funding Opportunity Number CMS -1G1-14-001 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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From list (in current form), identify top 3 short term priorities, and top 2 long term o From there assign out subgroups on a given policy o Each subgroup will be made up of subject matter experts on a given policy, to delve further into the work in a more efficient manner o Tasked with completing the Policy Issue Identification Form that the group created; will take additional research to complete; identify all elements – at what level (state, local), what is the impact, scope of impact, unintended consequences o Come back to entire Workgroup to report out; either toss or lay out path for moving forward o Workgroup would lay out strategic action plan, then subgroup tasked with executing, gathering support needed, etc. How define short term – 1 to 6 months? o Propose short term to mean between now and Feb 1 o Also those actions before Feb 1; that have time sensitive deadlines, need to meet to be ready for Feb 1 o Triage issues that need to be done by end of year Ideas for short-term (by end of year) o State applied for SAMSHA funds that will potentially fund Community Mental Health Centers; if SIM wants to provide comment/ input on how can be used to support integration, need prior to Feb 1 o Certified Community Behavioral Health Clinic (CCBHC) planning grant o Will lead into comments on ACC 2.0 comments; how do these various initiatives tie together o Need a strategic vision on how can utilize and leverage these various opportunities to achieve multiple objectives o Strategic alignment versus pursing each individually Brief background on CCBHC o Different payment models proposed o Comment on what might mean for state system overall, how work with integrated care Additional ideas for prioritization: o Cultural competency training among physicians, many unaware of need for cultural competency for DD/ID population  Possibly making mandatory credentialing item through CME  Dave Young, Irene Aguilar might get behind  Alliance received funding for a type of training  PCT Training (person-centered training) not related/RFP Being issued  Explore options for legislation for CC Training for HCP in DD/ID – How can this training be expanded?  Work with Workforce WG  Also expand training in area of suicide prevention Does policy mean program design and implementation or legislation? o Tara Smith clarified SIM would include both legislation and program design under policy o Major policy recommendations/decisions/actions will go through Steering Committee, in some cases to Advisory Board, decisions that need immediate attention can probably be expedited  If we take things to Advisory Board, how long will those take to go through, how much autonomy do we have?  Tara Smith clarified: in a lot of cases, issues will be deferred to your opinion as a group of experts; if you make a recommendation that does not align, then we will take a look at that at the time it occurs  It could take time for Advisory Board to get us back the feedback that we need For the CCBHC (SAMHSA) grant, would need a formal recommendation from SIM within a month o Shane is going to post an overview of the CCBHC grant from SAMSHA so the group can make some decisions around that opportunity or make recommendations

The Project described was supported by Funding Opportunity Number CMS -1G1-14-001 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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This is a top priority; collectively, group members will need to go onto Basecamp, review materials, provide feedback and come to next meeting ready to discuss o Use Policy Issue Identification Form to test o Some work that other groups that are doing on this SAMSHA grant, want to align our work with others (same issues with Workforce, the BHTC that is already defining competencies, etc.) o Sub-workgroup identified: Carol Bruce-Fritz, Chris Habgood, Jennifer Miles (member of public)  Next workgroup meeting – rescheduling education sessions  Other ideas for short or long term policy priorities o Moving away from diagnosis based treatment a top long-term priority o Look at other efforts that have taken place on this front in the last year; within HCPF and other; community living advisory group (LTTS), task force re: making use of Colorado Regional Centers for DD/IDD; findings of gap analysis o Come up with recommendations about what policies need to be change and how; complete that assessment by Feb 1, in terms identifying barriers, starting to identify strategies for moving forward o How look at diagnosis as a barrier; how look at through the lens of integration o Sub-group: Ellen Jensby, Marijo Rymer, Carol Bruce-Fritz, Shane Mofford, Jennifer Miles, Chris Habgood (optional)  Top short-term priorities: o CCBHC grant  Top long-term priorities: o Diagnosis basis of services - what policies need to be changed/how o Work with HIT to identify policy priorities, but now immediately on group’s radar

Action Items: Topic

Responsible Party

Deadline

1.

Review Policy Buckets and Priorities document on Basecamp and provide comments (if needed)

All Workgroup Member

Prior to next meeting

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Sub-workgroup on Certified Community Behavioral Health Center (CCBHC) grant will begin work; post information on Basecamp for group members to review and provide comment on; all members should come prepared to discuss at next meeting

Shane Mofford; Carol Bruce-Fritz; Chris Habgood; Jennifer Miles; All Workgroup Members

Prior to next meeting

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Sub-workgroup on diagnosis requirement will begin work

Ellen Jensby; Marijo Rymer; Carol Bruce-Fritz; Shane Mofford; Jennifer Miles; Chris Habgood

Prior to next meeting

The Project described was supported by Funding Opportunity Number CMS -1G1-14-001 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services.