Confidentiality and Release of Information Webinar

January 20, 20171

Webinar Participants• Bruce Copley (Panelist)

Director, Santa Clara County Department of Alcohol and Drug Services

• Gary Tsai (Panelist)Medical Director and Science Officer, LA County Substance Abuse Prevention and Control

• Victor Kogler (Project Director) Vice President, CA Institute for Behavioral Health Solutions

• Elizabeth Stanley-Salazar (Moderator) Project Manager, CA Institute for Behavioral Health Solutions

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Notice of Proposed Rulemaking

SAMHSA Announcement: New Rule Improves The Exchange of Medical Information January 2017

(See Handout 1 in handouts section of webinar)

Federal Register: Confidentiality of Substance Use Disorder Patient Records 1/18/17(See Handout 2, e-mailed to participants

prior to webinar)

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CLIENT CONFIDENTIALITYJANUARY 20, 2017

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Client Information Exchange42 C.F.R and the move to integrated healthcare

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GROWING DEMAND FOR INTEGRATED PATIENT HEALTH RECORDS• The move to “Whole Person Care” and emphasis

of coordinated Behavioral Health services.• Growing understanding of how chronic health

conditions are associated with Behavioral Health issues.

• Chronic physical healthcare management requires a behavioral health components.

• The realization that behavioral health and physical health currently work in silos with little interface or ability to aggregate patient data for delivery of coordinated healthcare6

HIPPA

• Required patient consent• Broad exceptions within the rule for patient

information exchange:– Treatment related exchange– Patient services for billing – Quality Improvement and outcome measures

• The exceptions is for the release of psychotherapy notes without the expressed authorization by the client

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SUBSTANCE ABUSE RECORDS42 C.F.R

• Applies to all health organizations that receive federal funds, federal tax benefits and all provides licensed under Medicare.

• Any organization that receives information under 42 C.F.R is required to abide by all of the rules for the re-release of patient information

• There are no exceptions for the use of patient information for quality improvement purposes

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Poll #1

How frequently do your SUD providers share information with physical and mental health providers?

o Very frequentlyo Sometimeso Rarelyo Never

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CRIMINAL JUSTICE RELEASE FORM(SEE HANDOUT 3 IN HANDOUTS SECTION OF WEBINAR)

• Designed for use in the treatment court environment

• The release is revocable at the time of disposition of the case

• Allows for the monthly Treatment Status Report to be sent to the court

• With this release counselors/therapist are able to release information within the court proceedings

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SANTA CLARA COUNTY HEALTH AND HOSPITAL PATIENT RELEASE FORM

(SEE HANDOUT 4 IN HANDOUTS SECTION OF WEBINAR)

• Policy developed for all components of the Health and Hospital System.

• Meets all applicable rules and regulations for patient information releases.

• As part of the policy all health care personnel are required to complete 42 C.F.R. training annually

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Comments & Questions

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Poll #2Do you imagine making changes to your release forms or consent management processes as a result of the Drug Medi-Cal Organized Delivery System Waiver?

o Yeso Noo Unsure

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Release of Information in an Evolving Substance Use Disorder Landscape

Gary Tsai, MD, FAPA, FASAMMedical Director & Science OfficerSubstance Abuse Prevention and ControlCounty of Los Angeles Health Agency & Department of Public Health

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OUTLINE

• Information Sharing in the Addiction Field– Opportunity – Challenges – Problem Solving – Summary

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OPPORTUNITY

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OPPORTUNITY• Drug Medi-Cal Organized Delivery System Waiver• Parity requirements• Addiction Medicine as an officially recognized medical

subspecialty• Addiction as a national priority (e.g., Surgeon General’s

report, opioid epidemic)

Elimination of the silo-ing of SUD treatment and integration into mainstream healthcare

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OUR GOAL

• Develop Universal Release Form (INTER-system info sharing)– Facilitate info sharing between County/contract SUD providers and

those outside of our network of care – health plans, Dept. of Mental Health, Dept. of Health Services

• Greater standardization of the release forms used within our network (INTRA-system info sharing)– Establish more standardized release form template to facilitate

greater/easier exchange of info between SUD providers– Provide clients an option to consent to share info with ALL providers

across our network to allow for more integrated SUD EHR capabilities, or to only consent to share info via the traditional method of specifying specific providers

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Challenges19

BARRIERS• “No” culture of info sharing

– Over-interpretation of 42 CFR Part 2– Extra work required of care coordination– Resistance toward changing the status quo

• Varied interpretations of 42 CFR Part 2– County Counsel – Provider legal counsel

• Less of an issue in systems that are County-operated due to the more limited number of legal counsels involved

• Technology– In SUD systems using an Electronic Health Record (EHR), EHRs that are

42 CFR compliant must, at a minimum, be capable of:• Segmentation or tagging of data protected by 42 CFR Part 2• Consent management

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Poll #3Do you have the technology infrastructure (e.g. EHR with consent management system) to facilitate electronic exchanges of information?o Yeso No o Unsure

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Problem Solving

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SOLUTIONS: ALIGNING OPPORTUNITY WITH CHALLENGES

• Presentation to Stakeholders– To providers/staff Clearly articulating the vision and goal of

changing info sharing practices is critical; buy-in from frontline providers is a must

• Talking to key provider groups or “champions” to build a case for why change is necessary

– To clients How we ask clients for consent is important• “Do you want to allow us to share your drug use with your other

health providers?”vs.

• “We’d like to be able to share your drug treatment information with other health providers to coordinate your care because we believe this results in better care. However, we wouldn’t share your information without your permission because some people have legitimate concerns about the sharing of this information. How do you feel about this and do you have any questions?”23

SOLUTIONS: ALIGNING OPPORTUNITY WITH CHALLENGES

• Interpretation– 42 CFR Part 2 is a law that requires contextual interpretation

• Given that 42 CFR is not entirely black and white, interpretations should be leveraged to advantage the patient, which oftentimes also advantages the system

• Presentation to legal counsels Need to help County and other legal counsels by contextualizing info sharing for them (e.g., what is the goal, why is info sharing important, what are the concerns, etc.)

– Recent changes to 42 CFR Part 2• Key areas of change:

– General consents for “entities” rather than specific individuals or providers, but if requested, must provide patients with a list of the entities to whom their info has been disclosed

– Modernization of rules to accommodate technology (EHRs & HIEs)24

SOLUTIONS: ALIGNING OPPORTUNITY WITH CHALLENGES

• Modification– Assess and address concerns of your legal

counsel/providers/staff/clients/stakeholders– Anticipate that a cultural change of this magnitude will take

time and persistence make incremental changes, if necessary

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DEVELOPING & OPERATIONALIZING THE FORMS(See Handouts 5 & 6 in the Handouts Section of the Webinar)

• Universal Release Form (URF)– Section I: Identify and engage all impacted entities, including their

respective legal counsels– Revocation of Authorization: The expiration period and

operationalization of the URF revocation and consent management process is complex (e.g., where will the URF “reside,” workflow of who needs to be notified when revocations occur, etc..)

• System-wide Release Form template– Section II: Desire to provide clients an option to consent to share with

the entire network, while also providing an option to consent via the traditional method

– Addendum added to address concerns about not specifying individual providers involved in the info sharing (also added to URF)

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Summary

• Identify goal & clearly articulate vision – How we talk about and present info sharing in the addiction field to

stakeholders (legal counsels, providers, staff, clients, etc..) is important and shapes interpretations of 42 CFR Part 2 and our ability to achieve our goals for a more fully integrated SUD system

• Identify concerns/barriers– Cultural resistance, legal interpretation, technology in terms of

consent management, etc.

• Address concerns while again emphasizing the end vision– Incremental changes may be necessary to achieve the future result we

want

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Thank you!Gary Tsai, MD, FAPA, FASAM

Medical Director & Science OfficerSubstance Abuse Prevention and Control

Los Angeles County Department of Public Healthgtsai@ph.lacounty.gov

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Liz Stanley-Salazar, Project Managerestanleysalazar@cibhs.org

(805) 728-5578

Paige D’Angelo, Project Coordinatorpdangelo@cibhs.org

(925) 963-8570

DMC-ODS Waiver Forum Staff

Grant funding provided by: The Blue Shield of California Foundation29