A Continuing Inside Look into the Partnership Workgroup on Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care
"Integration" of behavioral health and primary care is a promising approach to enhancing care, enabling patient safety and improving quality. Technology-enabled tools, including electronic health records (EHRs), clinical decision support, and standards-based interoperability, can enable integration to achieve these goals.
Since late 2019, a workgroup sponsored by ECRI and the Healthcare Information and Management Systems Society (HIMSS) Electronic Health Record Association (EHRA) has been developing recommendations on use of health information technology (IT) to facilitate integration of behavioral health with primary care. A project overview described the workgroup's three-pronged approach: (1) screening for behavioral health issues, (2) clinician documentation, and (3) sharing information among clinicians, patients, and authorized parties.
Clinicians' ability to access and share behavioral health information (before and after an encounter) is central to the value of integration. Sharing can include access to the medical record, messaging, and interoperability and health information exchange. Behavioral health clinicians and primary care clinicians need access to each other's data, including care plans, ideally shared care plans.
Organizational and technical approaches to sharing depend on the integration model (e.g., enhanced collaboration, physical colocation, and full integration). Decisions about integration models and sharing are influenced by choices on whether to move to a single EHR or to retain different EHRs for behavioral health and primary care.
Although sharing needs are similar across models, the means of sharing and technology needs can differ. Regulations and organizational policies (reflecting regulatory interpretations) identify what can be shared.
The information that needs to be shared includes: screening information (e.g., depression screens), medical history (including notes), diagnostic test results and medication lists, behavioral health history, discharge summaries, and prior treatments. Consistent with HIPAA, psychotherapy notes would not be shared.
There are several reasons for sharing to be supported, including: emergency care, hand-offs between behavioral health clinicians and primary care physicians (PCPs), referrals, prior authorization, coordination among behavioral health clinicians, hand-offs between psychiatric hospitals and community behavioral health clinicians, coordination among PCPs and other nonbehavioral health clinicians and behavioral health clinicians, and billing.
Despite the value of sharing, access to behavioral health documentation is often restricted by patient preferences, organizational policies, federal and state laws, and technology configurations reflecting understanding of laws and associated policies. For optimal sharing, barriers to access should be intentional, no more than needed for compliance, and respectful of patient preferences.
Unlike what many believe, the Health Insurance Portability and Accountability Act (HIPAA) does not limit clinician access to medical records created by behavioral health clinicians, although it protects psychotherapy notes as outside the HIPAA-defined record. Other federal regulations (e.g., 42 CFR Part 2), cover records created by federally funded substance-use-disorder treatment programs. Congress recently enacted changes to 42 CFR Part 2 (to align with HIPAA) in the CARES Act, responding to the COVID-19 pandemic. More recently the federal government finalized revisions to 42 CFR Part 2 to simplify and clarify its requirements. Technology, including data segmentation, can be both challenging and beneficial in sharing information consistent with laws and regulations.
Sharing can occur through joint record access. It is enhanced with a shared EHR but can also be achieved across multiple EHRs via interoperability, integration, and data exchange using standards like those maintained by HL7®. To more effectively use standards, we need common clinical vocabularies and greater sociocultural understanding across professions using different terminologies (e.g., Diagnostic and Statistical Manual of Mental Disorders [DSM-5] vs. ICD-10 or SNOMED CT), documentation methods, and patient views (e.g., chronic vs. episodic).
Sharing also requires secure messaging, included in many EHRs, as well as secure interorganizational messaging (e.g., the Direct secure healthcare email standard).
The workgroup is identifying recommendations for sharing, with a focus on functionality and data fields. High-level product and implementation requirements will follow.
One requirement is ensuring that functionality meets the needs of both behavioral health and primary care clinicians. In addition, privacy and security support will be essential, including compliance with federal and state laws and regulations and support for organizational policies and configuration decisions, including access and consent.
Another focus area will be standards and needs for data documents and elements (e.g., Consolidated Clinical Document Architecture [C-CDA] and HL7® FHIR® [Fast Healthcare Interoperability Resources]) as well as shared care plans and discharge summaries, including assuring that a receiving organization can maintain the fidelity of received data and information on segmentation and consent.
A final topic will be communication between clinicians, including messaging and shared access to clinician notes and patient data, referrals within and outside of the integrated practice and closing the loop on referrals, cross-organizational data sharing, and confirmation that useful sharing has occurred.
The goal of the workgroup is to provide guidance for technology innovation as well as for clinician use and integration of these tools.