Facilitating data exchange

Behavioral healthcare is in the midst of an unprecedented trend toward sharing patient/consumer data between and among care providers. While privacy is (and should be) a key consideration, the advantages of secure data sharing include reducing polypharmacy, initiating and advancing electronic health records (EHRs), and more timely information exchange resulting in higher-quality care.

Not many years ago, the implementation of so-called health information exchanges (HIEs) and similar information-sharing networks, such as regional health information organizations (RHIOs), was heralded by many as the nirvana needed to create the secure transparency that would lead to seamless management and sharing of patient/consumer health records.

Yet the path from envisioning HIEs to real-world implementation has not been a straight “A-to-B” process. Instead, it has included (and continues to include) stops, starts, and a variety of curves along the way. This is not a bad thing. In fact, it's a natural course for promising and eventually successful technology.

Data sharing begins with EHRs

The first step toward HIE participation is adopting/using EHRs to ensure your organization's clinical data are stored and managed electronically and can be shared with other appropriate parties. Former President George W. Bush's call for every American to have an EHR by 2014 added more urgency to finding more effective ways to share patient/consumer information. The rate of EHR adoption likely will increase given President Barack Obama's intention to invest $50 billion in healthcare infrastructure, EHRs, and e-prescribing.

After implementing an EHR system, the next step some organizations take toward HIE involvement is sharing information in a “point-to-point” communications environment. This involves exchanging patient/consumer data with other information systems within the enterprise or simply exchanging data with two or three other providers via customized interfaces.

The next stage of HIE participation can be involvement in a RHIO, which many view as a manageable option and predecessor to a national health information network (NHIN), which is still in the formative stages. As its name suggests, a RHIO is comprised of multiple providers in a geographic region that share EHR information. A central routing point collects or routes data (depending on the architecture) to and from providers. Collecting the data can support provider portals to view patients/consumers' information. Routing the information provides a more proactive data-sharing method because the needed information is sent to the appropriate provider. This is sometimes referred to as a “hub-and-spoke” data-sharing method.

Evolving HIE standards

While behavioral healthcare has lagged slightly behind primary and general healthcare in implementing HIEs, your organization and patients/consumers can realize the benefits of HIE participation as long as you keep a few factors in mind.

First, there are no 100% agreed-upon standards for exchanging patient/consumer information between and among providers. In fact, information is shared using three primary methods:

• ASTM CCR—Continuity of Care Record

• HL7 CDA—Clinical Document Architecture

• CCD—Continuity of Care Document

Unfortunately, all three standards are oriented predominately toward primary and ambulatory care environments. While CCD has the broadest overall backing, there is no consensus standard at this time.

Behavioral healthcare also has data-exchange requirements that do not commonly exist in primary and ambulatory care settings. For example, HIE data-exchange structures do not have ideal ways to handle behavioral health structured-text entries for documents such as progress notes and treatment plans. Furthermore, risk assessments, for example, do not have national coding standards. As such, providers cannot be made aware of these issues without reading a free-form text summary. So although documents can be transferred among providers, they are only “human readable” and can't be automatically converted into data (e.g., Level One or Two CDA or CCD), which makes working with the information difficult.

Another data challenge for HIEs relates to DSM multiaxial diagnoses. The CCD model lists diagnosis as a type of “problem.” This can be coded with ICD-9 codes, but there is no area for recording DSM multiaxial diagnoses.

An additional HIE-related data-exchange problem is the HIE “data snapshot” used by the three document standards to provide a snapshot of a patient/consumer's pertinent clinical, demographic, and administrative data. This critical function is the method one healthcare entity uses to aggregate and forward patient/consumer data to another in support of care continuity. Unfortunately, the HIE snapshot was not designed for long-term care environments such as mental health, mental retardation, and substance abuse treatment, in which data summaries need to be generated not just at the end of an episode but upon request over the care period.

HIEs' focus primarily has been on ambulatory and acute care, creating a lag in the development and refinement of data exchange in behavioral healthcare. However, that shouldn't deter your organization from moving forward with an HIE strategy.

Embracing data exchange

Despite these challenges, your organization can take steps toward HIE involvement, positioning your organization for when HIEs become the de facto method of patient/consumer data exchange between all types of providers.

• If you haven't implemented an EHR, take steps to do so now before moving ahead with HIE involvement. Use your own resources or seek assistance from a knowledgeable technology partner. Look for opportunities to fund your EHR implementation with funding that might be available from federal initiatives and programs.

• If your resources are extremely limited and you interact with a small number of providers, start your HIE involvement with a peer-to-peer or small hub-and-spoke network.

• If your area has a RHIO, find a way to participate. If not, start discussions with other providers about creating one.

• Realize that HIE data standards and data-exchange methods are oriented toward encounter-based primary care settings and not behavioral healthcare environments. Even with those limitations, there are workarounds and ways to exchange pertinent patient/consumer information.

• Keep your patients/consumers at the center of your efforts. They are the ultimate beneficiaries of the increased efficiency and quality of care made possible through HIEs.