Although health care providers have long recognized that many of their patients have both behavioral and physical health needs, behavioral and physical health care have long been provided -- and paid for -- separately. However, in light of growing awareness of the prevalence and cost of comorbid behavioral and physical health conditions and increased recognition of how addressing those conditions in a coordinated manner can improve outcomes and reduce costs, the health care system is increasingly embracing care delivery models that integrate behavioral and physical health care and connect providers of such care to one another.
Electronic health information exchange can help facilitate the integration of behavioral and physical health care. However, federal and state strategies are necessary to address common barriers to HIE.
Benefits of Integration of Behavioral, Physical Health Care
According to a national comorbidity survey, a significant number of adults have comorbid physical health and behavioral health conditions. Nearly 70% of adults with mental illness have co-occurring medical conditions, while 29% of adults with physical health conditions have comorbid mental illness. Rates of high blood pressure, asthma, diabetes, heart disease and stroke are higher for individuals with mental illness than for those without mental illness. Comorbid behavioral health and physical health conditions are also costly; New York's Medicaid program found that 82% of potentially preventable 30-day hospital readmissions were for persons with behavioral health conditions, costing the state $665 million. Nearly 60% of those readmissions were due to physical health conditions.
Scores of randomized controlled trials have found that collaborative care interventions -- those that use an interdisciplinary team to address mental health conditions in primary care settings -- improve quality and outcomes for some of the most prevalent and costly behavioral health conditions: depression and anxiety. In the Community Care of North Carolina (CCNC) model, Medicaid enrollees receive physical and behavioral health services through medical homes and care management through local networks made up of physicians, hospitals and social service agencies. To support integration of behavioral health, CCNC decided to hire a physiatrist and behavioral health coordinator in each of its 14 networks across the state and add functionality to their electronic care management tool to flag members in need of behavioral health assistance. CCNC's model has been shown to improve quality and reduce costs, saving the state millions of dollars annually.
With consensus growing around both the need for and the benefits of integrating services, some states have embraced a statewide approach to assessing and supporting the integration of behavioral health services in primary care and community clinic settings. The Integrated Behavioral Health Project (IBHP) in California, for example, has conducted numerous studies and funded over thirty initiatives to identify and promote best practices that support integrated behavioral and physical health care delivery. These efforts have produced a series of recommendations -- including the need to standardize data systems and utilization and to improve bi-directional data sharing among providers -- that offer a roadmap for broader implementation across the state.
Electronic HIE Can Help Facilitate Care Integration
Behavioral and physical health care providers often have separate administration, financing and regulatory structures. But a key prerequisite to coordination is for behavioral and physical health care providers to exchange information about their shared patients' care, including their treatment plans, medications and lab results. Electronic HIE can make access to this information available in one place, instantaneously.
In New York, for example, behavioral and physical health information is available through the Statewide Health Information Network of New York, or the SHIN-NY. Clinical information from participating medical and behavioral health providers is available through the SHIN-NY to health care providers who obtain patient consent to access their information. The SHIN-NY is designed to enable providers to use a single consent form, which complies with stringent New York laws governing the confidentiality of sensitive health information, in order to access both physical and behavioral health information. Thus, the SHIN-NY can help both types of providers to quickly and easily access their shared patients' full health record and, ultimately, to coordinate the care they provide.
Barriers to the Electronic Exchange of Behavioral and Physical Health Data
One of the barriers to the electronic exchange of behavioral health information are state laws or regulations that impose special protections on such information or that limit what types of health care providers can do with behavioral health information they generate. Most electronic systems do not have the capacity to tag and separate patient information that is subject to more stringent privacy standards from patient information that is not. As a result, such laws and regulations create obstacles to the sharing of behavioral health information through an HIE.
However, providers often interpret confidentiality laws as more restrictive than they actually are. For example, some providers believe that HIPAA, which provides a federal baseline of privacy protection for patient health information, requires patient authorization to disclose information for treatment purposes, when, in reality, no patient authorization is required. Another common misconception is that HIPAA places tighter restrictions on the disclosure of behavioral health information than on physical health information, which is generally not true either.
Health care providers also often misunderstand the federal substance abuse confidentiality regulations -- or Part 2 regulations -- which require patient consent for disclosure of certain drug and alcohol treatment information except under limited circumstances. Many health care providers believe that the Part 2 regulations restrict disclosures by general medical providers who deliver a mix of substance abuse and other health care services. In fact, the regulations apply only to the records of federally assisted alcohol and drug abuse programs, which are limited to the following:
- An individual or entity (other than a general medical care facility) that holds itself out as providing and provides alcohol or substance abuse diagnosis treatment or referral for treatment; or
- An identified unit within a general medical facility that holds itself out as providing and provides alcohol or substance abuse diagnosis, treatment or referral for treatment; or
- Medical personnel or other staff in a general medical care facility whose primary function is the provision of alcohol or substance abuse diagnosis, treatment or referral for treatment and who are identified as such providers.
Thus, many health care providers who offer substance abuse services as part of general medical or behavioral health care services but do not fall within the categories above are not subject to Part 2's tight restrictions.
Strategies To Overcome Barriers
Stakeholders have developed several ways to surmount the barriers described above. For example, HHS recently released clarifying guidance to ensure that providers understand that HIPAA has allowed and continues to allow uses and disclosures of behavioral health information for treatment, payment and health care operations without patient consent. To ensure provider understanding, the guidance also reiterated the rules about when health care providers may:
- Communicate with a patient's family members, friends or others involved in the patient's care;
- Communicate with family members when the patient is an adult;
- Communicate with the parent of a patient who is a minor;
- Consider the patient's capacity to agree or object to the sharing of their information;
- Involve a patient's family members, friends or others in dealing with patient failures to adhere to medication or other therapy;
- Communicate with family members, law enforcement or others when the patient presents a serious and imminent threat of harm to self or others; and
- Communicate to law enforcement about the release of a patient brought in for an emergency psychiatric hold.
The Substance Abuse and Mental Health Services Administration, the federal agency with authority to enforce the Part 2 regulations, also has taken specific steps to help health care providers understand how to comply with the regulations while engaging in electronic HIE.
Specifically, the agency released a document called "Frequently Asked Questions: Applying the Substance Abuse Confidentiality Regulations to Health Information Exchange (HIE)." The guidance interpreted the Part 2 regulations in several ways that provided comfort to Part 2 providers interested in participating in electronic data exchange initiatives. Among other things, the guidance stated that a single consent form may be used to authorize disclosure of records from a Part 2 provider to multiple providers participating in an HIE or other data-sharing arrangement.
To remove barriers to information sharing at the state level, some states have enacted legislation to replace their existing patchwork of privacy laws with a single set of requirements governing the electronic exchange of information. For example, North Carolina passed legislation that supersedes other state privacy laws with respect to information sharing within the state's electronic health information network, thereby authorizing the exchange of all data within the network in accordance with HIPAA's broad privacy standards.
These and other strategies for overcoming barriers to information sharing between behavioral and physical health care providers (both electronically and through more traditional channels) were recently outlined in a Robert Wood Johnson Foundation-sponsored white paper.
Improving Coordination Between Behavioral and Physical Health Care
With many health care providers, including some behavioral health providers, eligible for payment incentives for sharing health information under the Medicare and Medicaid EHR Incentives Program and with participation growing in payment reform initiatives like accountable care organizations and medical homes that reward providers for coordinating care, information sharing between behavioral and physical health providers should continue to grow.
How quickly this growth occurs will depend on how effective providers and policymakers are at identifying barriers and developing strategies to overcome them.