PowerPoint Presentation

Series 1: Meaningful Use for Behavioral Health Providers9/2013From the CIHS Video Series Ten Minutes at a Time

Module 7: Meeting the PBHCI Grant HIT-Related Expectations in the Bulleted List of Requirements

Welcome to the SAMHSA-HRSA Center for Integrated Health Solutions video series Ten Minutes at a Time. This information on how to meet the standards for Meaningful Use and how to select and successfully implement an electronic health record system is organized into brief, convenient modules targeted to behavioral health providers. This is Series 1: Meaningful Use for Behavioral Health Providers, Module 8, Meeting the PBHCI Grant HIT-Related Expectations in the Bulleted List of Requirements. It is targeted to the PBHCI grantees in all Cohorts. The goal of this module is to support understanding of these grant expectations.1Module 4 Outline Overview of grant expectations and some key terms

Meeting the bulleted list of requirementsWhat the requirements meanLessons learned for implementationSAMHSA-approved work-arounds when the ability cannot be demonstrated as written in the grant (implemented in consultation with GPO).

We will begin by reviewing the grant expectations listed in the Request for Proposals, and discussing some key terms. Then we will review each requirement in the list, explain what it is about, and cite some lessons learned. Even if you are not a PBHCI grantee, you may be interested in these. If an organization finds that, for some reason it is unable to meet a requirement, there is a set of SAMHSA-approved workarounds for some of these tasks.

2Grant Expectations*SAMHSA expects PBHCI grantees to achieve Meaningful Use Standards, as defined by CMS, by the end of the grant period; to that end, applicants must propose how they will develop and demonstrate the ability to:Submit at least 40% of prescriptions electronically (as allowable given state-specific laws regarding the use of e-prescriptions for controlled substances);Receive structured lab results electronically; Share a standard continuity of care record between behavioral health providers and physical health providers; andParticipate in the regional extension center program.

*Page 9 of Request for Applications (RFA), No. SM-12-008, PBHCI

The grant requires all of the grantees to achieve the standards for Meaningful Use, as defined by the Center for Medicaid/Medicare Services (CMS). This was discussed in some detail in Module 7. The grantee must also demonstrate they have met the standard by implementing the activities in the bulleted list of requirements. This module concerns this list.

3Key TermElectronically Describes the computer-based transmission and/or receipt of data. Used in discussion of prescriptions; receipt of lab results; and the transmission/receipt of patient information.

Https://questions.cms.gov/faq.php?id=5005&faqId=2857

The grant uses the term electronically to refer to different types of processes where information is transmitted and/or received. It is used in the discussion of ePrescribing, the ability to receive structured lab results and the transmission and receipt of patient information in the Continuity of Care Document. This means that the standards for transmitting and receiving patient data are in an electronic format. Data is structured, which means that the computer can understand and search it as noted in Module 1. It must be fully integrated into the patient record, as opposed to scanned in and attached. Only then is the information actionable and shareable.

The national standards for data and technology can be found in Meaningful Use specifications: Https://questions.cms.gov/faq.php?id=5005&faqId=2857

4ePrescribingSubmit at least 40% of prescriptions electronically (as allowable given state-specific laws regarding the use of e-prescriptions for controlled substances)

Closely related to Meaningful Use Core Objective #4 Objective: Generate and transmit prescriptions electronicallyMeasure: More than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/e-prescribing

Lets look at the requirement concerning ePrescribing. This requirement is actually a reference to Core Objective 4 of the Meaningful Use standard explored in Module 3, Part 1. The grant language is in the slide, and the Core Objective very similar. The denominator for the objective is all of the permissible prescriptions the EP writes, and the numerator is 40% of those prescriptions.

The link provided will bring you the Meaningful Use specifications for the Objective.http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/e-prescribing5Stage 1 Meaningful Use

Improve Quality, Safety, Efficiency

5 Core and 2 Menu Objectives related to medication

Systemic strategy for medication management

Since ePrescribing is becoming very common, there are usually few issues related to meeting the grant requirement. If there are no prescribers employed by the grantee organization, the grantee is still held to the requirement. The workaround is to ensure that the Active Medication and Medication Allergy lists are populated and that Medications Reconciliation is performed. When new medications are entered it triggers the drug interaction clinical support. 6Lab Results and Meaningful Use

Diagnostic test results are part of the minimum data set for the CCR/CCD and are included in two Core Objectives re: Patient Summaries. They are also included in patient summary data for two Menu ObjectivesLab Results Data Standard Developed for Meaningful Use LOINC Logical Observation Identifiers Names and CodesNot mandated by CMS!

As noted in Module 4, the ability to receive lab results is passive functionality that the EHR must have to be certified. A lab interface makes this functionality active and allows the grantee to receive results electronically as the grant requires. You will find that there is no Core Objective that requires structured lab data per se. However, diagnostic test results are required by three of the Core Objectives, including one of the bulleted requirements in the grant. The standard for structured lab data required for EHR certification is the Logical Observation Identifiers Names and Codes (LOINC).7Lessons LearnedEHR may have capacity to receive results (as required for certification), but lack functionality to utilize the results

May lack interface

May have interface butIt is limited to working with only one or two labsIt costs more than anticipated It lacks other necessary utility such as the ability to comment on out-of-range results, signing off on single or batched results, etc.

Labs may not be willingMay not want to invest in interface functionalityMay not have resources available to work with BH providers, who usually have low order volume

Here are some lessons learned concerning this grant requirement. As noted in Module 2, some EHRs meet only the bare minimum that is required for certification. For example, the EHR may have a screen to display lab results, but may not have an interface to import the lab results electronically. Even if an interface is available, there may be unanticipated costs, or it may be limited to working with only one or two labs. 8Lab Results WorkaroundRefine cohort and data parameters - applies only to (a) PBHCI enrollees (b) who are entered into the EHRS (c) PBHCI grant Health Risk Assessment lab results

Access Guidance for ImplementationMenu Objective #2: Incorporate clinical lab test results into EHR as structured datahttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/clinical-lab-test-results

A Case for Manual Entry of Structured, Coded Laboratory Datawww.ncbi.nlm.nih.gov/pmc/articles/PMC1380191

When these barriers to meeting the grant requirement cannot be effectively addressed, there is a SAMHSA-approved workaround that should be used that allows for manual entry of data to meet the requirement.

Begin with a clear understanding of the requirement parameters. It only applies to PBHCI enrollees, and only to the PBHCI project - related lab results. The next step is to access the CMS Meaningful Use specifications for Menu Objective 2, which provides guidance on manual data entry. This is briefly described in Module 4.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/clinical-lab-test-results

Errors in lab result entry have a much lower level of risk than errors in medications entry, and the linked article provides a framework for implementation. The grantee project budget should have allowed for the expense of the electronic interface. These resources can be applied to the costs associated with meeting this grant requirement.

www.ncbi.nlm.nih.gov/pmc/articles/PMC1380191

9Continuity (or Transition) of Care Record (CCR) Minimum Data Set1) Allergies and other adverse reactions2) Medications (including current meds) a. Admission medications history b. Hospital Discharge Medications (if hospital) c. IV Fluids administered (if hospital) d. Medications administered3) The problem list (diagnoses) a. Active problems b. History of past illness c. Hospital Admission Diagnosis (if hospital) d. ED diagnosis (if hospital) e. Discharge diagnosis4) List of surgeries (if hospital)5) Diagnostic results (i.e., labs, imaging, etc.)

Originating Entity InformationPatient Informationhttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/transition-of-care

The grant requires the exchange of patient information and specifically cites the Continuity of Care Document (CCD) or Continuity of Care Record (CCR). The CCR has many applications and it requires a minimum set of patient health information. The elements in the list that are not grayed out apply to ambulatory care practice discussed in Module 1.

http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/transition-of-care

10Example of the Continuity (or Transition) of Care Document(CCD) Minimum Data Set

(See Module 5 for more information)http://www.corepointhealth.com/sites/default/files/whitepapers/understanding-the-continuity-of-care-record-ccr.pdf

Here is an example of what the CCD minimum data set looks like, and a link to a White Paper that gives a high level overview. It is discussed in more detail in Module 9.http://www.corepointhealth.com/sites/default/files/whitepapers/understanding-the-continuity-of-care-record-ccr.pdf

11Exchanging the CCD and Meeting the Requirement for Joining the Regional Extension CenterRegional Extension Centers (RECs) BH involvement varies state by state but can still access assistance through Web siteshttp://www.healthit.gov/providers-professionals/regional-extension-centers-recs

State Health Information ExchangesBH involvement varies state-by-statehttp://www.healthit.gov/providers-professionals/state-health-information-exchange

Nationwide Health Information Network Direct (NwHIN Direct)Point-to-point secure messaging system for the transmission and receipt of patient information over a network of providershttp://www.healthit.gov/policy-researchers-implementers/nationwide-health-information-network-nwhin

The exchange of patient information and the last bulleted requirement to join the Regional Extension Center are related. The Regional Extension Centers or RECs provide technical assistance and training for implementing patient information exchange, and the state Health Information Exchanges support this activity. If your REC is no longer in service, the state-specific resources should be your first stop.

Even if Behavioral Health providers are not able to participate in state HIE over the Internet, they can still meet all of the standards for Meaningful Use by using a special, secure messaging system, similar to an email system. This also meets the requirements of the grant. This system adheres to security protocols and procedures that are collectively referred to as the Nationwide Health Information Network Direct. Participation is inexpensive, and the format accommodates the requirements for exchanging both HIPAA and 42 CFR Part 2 patient health information. Visit your state Health Information Exchange site for information about obtaining a Direct account.

http://www.healthit.gov/providers-professionals/regional-extension-centers-recs http://www.healthit.gov/providers-professionals/state-health-information-exchangehttp://www.healthit.gov/policy-researchers-implementers/nationwide-health-information-network-nwhin

12SummaryCommunity Behavioral Health Providers can (and the grant requires the grantees to) participate in Health Information Exchange and meet the standard for Meaningful Use

It also requires the active demonstration of the ability to meet this standard by the implementation of the bulleted list of activities

Obstacles and delays caused by external factors are not unusual. Remember that in most cases, a SAMHSA-approved work around can be applied

So, here are the important things to keep in mind. PBHCI grantees are required to meet the (Stage 1) standard for Meaningful Use, and also demonstrate the ability to actively meet the requirements in the bulleted list. The requirements in the list may present more of a challenge than is initially anticipated. Regardless of the issues, there is always a path to success for every grantee. It is wise to anticipate barriers and obstacles, and remember that persistence pays off. When concerns arise, contact your CIHS liaison and your GPO to talk them through. 13We Have Solutions for Integrating Primary and Behavioral Healthcare

Contact CIHS for all types of primary and behavioral health care integration technical assistance and training needs

1701 K Street NW, Ste 400 Washington DC 20006

Web: www.integration.samhsa.govEmail:integration@thenationalcouncil.orgPhone:202-684-7457

Prepared and presented by Colleen ODonnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions

Our thanks go to SAMHSA and to HRSA for providing support to the Center for Integrated Health Solutions (CIHS) for this and many other forms of training and technical assistance related to the integration of primary and behavioral health care. Please visit our web site at www.integration.samhsa.gov, email us at integration@thenationalcouncil.org, or just pick up the phone and give us a call at 202-684-7457.

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