Integrating Care: Moving Beyond Interoperability to True Collaboration, Part IV


We’re nearing our destination! In this blog series over the past several weeks we’ve identified the importance of integration and collaboration as expressed through the impacts of severe mental illness (SMI). We’ve seen the practical use of applications like referral process automation. We’ve examined how standards-based transaction and data elements can provide visibility across systems into a patient’s well-being. In short, we have facilitated communication and the collection of massive amounts of powerful information about individuals and entire populations. So, what’s still lacking? Two words – expansion and context.

Let me explain.

The thing we need to expand is our very definition of integration. We can define integration by the ability to share information between organizations and across entire systems but that doesn’t ensure that the information is consumed or even that the data is helpful. A more helpful definition of integration consists of not only of having the ability to share information, it requires that the data is received and disseminated within clinical workflows that have been optimized to make the delivery of holistic care seamless.

Likewise, the data that’s being shared within a given clinician’s daily workflow has to have context. It’s not enough to know that a patient is experiencing co-morbid conditions. We must take a broader view. We have to ask, what social determinants of health are causing or at least impacting the co-morbid conditions the patient is living with? Social determinants can range from housing to family support. It’s only when we feed the physical, mental and social data into an easily consumable clinical workflow that we begin to fully realize the benefits of integration and true collaboration.

A given patient may interact with a vast range of services including education, justice, social service and more. Care providers and modalities must be assembled in the following forms: patient-centered team care, population-based care, measurement-based care, evidence-based care and accountable care.

Moving beyond interoperability to true collaboration is an audacious goal but the reasons to pursue this goal are compelling, the applications are numerous, and the technology and systems are available. If we collectively work to define integration is its fullest terms and to contextualize the data produced, we will have created a holistic care delivery system that produces far more positive outcomes and reduced costs.


Integrating Care: Moving Beyond Interoperability to True Collaboration, Part III


We began traveling down the road to integration and collaboration by noting the importance of this journey; severe mental illness (SMI) impacts both lifespan and quality of life. In addition, fragmented care drives higher costs. Along the way we’ve been witnesses to the practical use of applications including referral process automation, integration with Acute Care Organizations (ACOs), and synchronized systems across Community Mental Health Centers (CMHCs) and Federally Qualified Health Centers (FQHCS). But any successful journey involves looking not only at the road directly in front of us but the landscape on the horizon. In this case the landscape we must look to is one marked by technology that can move us beyond just basic information sharing.

To enable true interoperability, we need to make use of technologies and platforms that integrate directly into the EHR. But there are further requirements. They must make use of standards-based transactions and data elements to support broad scale connections. Without visibility across systems we can’t pave the way for network-to-network connectivity in the future. So, what’s so important about network-to-network connectivity and what are its requirements?

This type of integrated connectivity requires tools that can aggregate information for segmentation and stratification. That opens a myriad of possibilities including:

  • Populations can be defined by relevant attributes
  • Data can be segmented by diagnosis, gender and utilization of services
  • Risk-based factors can be ranked based on outcomes, workflows and treatment
  • Assessments can be made spanning high risk/cost vs. low risk/cost

The ability to synchronize across systems and aggregate information for segmentation and stratification holds great promise because everyone benefits.  Not only can an individual be treated holistically, the treatment outcomes of groups of people can be monitored and analyzed so care can be optimized and applied to communities elsewhere.

These are exciting times that hold much promise but there’s a final stop we absolutely must make on the road to true collaboration – without that stop we won’t ultimately arrive at our destination. We’ll examine that signpost in Part IV of Integrating Care: Moving Beyond Interoperability to True Collaboration.

Netsmart: SAMHSA Makes Progress with 42 CFR Part 2 Final Rule; More Still Needed

As the leading knowledge and technology partner for human services providers nationwide, Netsmart provides expertise, technology, and healthcare connectivity and integration solutions that help addiction treatment, behavioral health and other human services providers deliver effective, outcomes-based services and care to more than 25 million persons nationwide. Netsmart clients include 500,000 users in 24,000 in provider organizations across all 50 states.  Netsmart applauds the Substance Abuse and Mental Health Services Administration (SAMHSA) for its efforts to update and modernize privacy regulations related to the confidentiality of alcohol and substance use treatment records. In developing the Final Rule, SAMHSA faced the significant challenge of balancing statutory limitations and guardrails with the need to address the varying interests of persons with a history of diagnosis, treatment or referral for substance use disorders (SUD) who wish to consent to disclose their medical records to their treating providers, share some of that information, or opt out of such disclosure.

Our analysis of this rule is based on the following principles:

1)  Whether and to what extent a person chooses to share his or her health information is fundamentally a decision that should lie with that person, not the Part 2 program, SAMHSA or the healthcare system. The ultimate goal of consent should be that any person – if they so desire – whether they suffer from a substance use disorder, mental illness, diabetes, cancer or heart disease – have the ability to share his or her health data with their healthcare providers, utilizing today’s technology, with equal simplicity.  The provisions of the Final Rule make this unattainable for the millions of people with substance use disorders.

2)  Many people who have a SUD are reluctant to share their data due to potential impacts on their employment, housing, family lives, relations with child welfare organizations, other personal reasons or just general stigma that is still attached to addiction and substance users.  It is important that those who do not want to share treatment information can easily and effectively carry out his or her desires.  These persons must be able to choose to opt-out (or not opt-in) to a Health Information Exchange (HIE) for sharing their SUD treatment information.

3)  Some persons want to share only segments of their data among their treating providers. Unfortunately, this is not achievable with today’s technology.  While certain electronic health record (EHR) vendors, such as Netsmart, are able to segment data, most other EHR and HIE vendors will need to modify their systems to perform, respond to and manage this type of segmented data. For this to happen, the federal government will need to design the standards and mandate this capability in some form of regulation (like the HITECH Act) and apply it to all EHR, HIE, population health vendors and care coordination providers. The cost of modifying all these systems will be significant. In the best case, Netsmart believes that a robust system capable of supporting this type of segmented data will not be available for 7-10 more years, rendering the potential for this type of data exchange moot for the near future.  In the interim, the vast majority of providers and HIEs will not spend the money to modify their systems to support it.

Unfortunately, the Final Rule retains the original rule’s discriminatory impact on people with a history of diagnosis, treatment or referral for SUD who wish to consent today to disclose their medical records to their treating providers using currently available EHR and HIE technology – just like patients with any other illness or chronic disease. For example, a person receiving treatment for diabetes can consent to share his or her data with their treating providers freely with the protection of HIPAA. But if that same person also has a history of SUD treatment and receives treatment from a provider subject to 42 CFR Part 2, that person cannot consent to share their data in the same way as the person with diabetes alone. This creates a discriminatory and unequal healthcare access playing field for persons receiving SUD treatment or with a history of SUD treatment.

The Final Rule made noteworthy progress in several key areas:

To Whom Consent

The Final Rule allows for a consent for the release of SUD treatment information to be executed to an intermediary, such as an HIE, Accountable Care Organization (ACO), Health Home or other care coordination entity whose members have a treating provider relationship with a patient. This simplifies the consent process by permitting disclosure of SUD information with a single patient consent to past, present, and future providers in a care coordination organization, but protects patient privacy by limiting that disclosure to providers that have a treating relationship with the patient.

 From Whom Consent

SAMHSA agreed with Netsmart’s position and chose not to adopt more stringent From Whom provisions.  The Final Rule allows for disclosure to and among the participants in an intermediary, such as an HIE, ACO, Health Home or other care coordination entity. Retaining the existing From Whom regulations allows for multi-party bi-directional consent to facilitate the exchange of a patient’s information among multiple treating providers. It also allows for re-disclosure between and among treating providers in a care coordination entity.

The rule also fell short in several important areas:

Lack of Parity:  List of Disclosures Requirement

The new simplified To Whom consent process is permitted only if the intermediary party has the ability to track and generate a List of Disclosures, which identifies the recipients of the SUD information for up to the prior two years. The List of Disclosures requirement for SUD information is more robust than the Accounting of Disclosures required under HIPAA.  Although the HITECH Act imposed a duty to account for disclosures for treatment (similar to the List of Disclosures), that requirement has not yet been implemented. In addition, the List of Disclosures must be implemented when the intermediary begins utilizing the general designation under the consent process. This may result in significant delays due to cost and technological limitations. Finally, while SAMHSA does not prohibit it, the agency requests that the costs for the List of Disclosures not be passed on to patients.

So in effect, in addition to not being eligible for HITECH Act Meaningful Use financial incentives in parity with physical health, behavioral health and addiction treatment providers now have a more stringent disclosure list compliance burden than medical providers.

Complex Re-Disclosure

The Final Rule only slightly modified the existing prohibition against re-disclosure, making it clear that only data that directly or indirectly identifies a patient as suffering from an SUD is subject to this prohibition. Any information that could potentially identify the patient as suffering from an SUD, such as name, diagnosis, medications or vital signs, each accompanied by the name of the Part 2 program, would be subject to the prohibition. The Preamble to the Final Rule confirms that the disclosure from one treating provider to another treating provider in an HIE would be considered a re-disclosure. Thus, the consent process described above using the retained From Whom provision is necessary to avoid the prohibition when addressing the disclosure and re-disclosure of SUD information in an HIE or integrated care environment.

Increased Patient Risk

These additional restrictions beyond what a person with a physical illness must endure heighten the risk to patient safety from a harmful drug interaction or other causes by making it more difficult and cumbersome for SUD patients

to consent to share medication history and other vital health information with clinicians/prescribers in the emergency department, urgent care and other primary care facilities. 

Impractical and Unattainable for HIEs

Many HIEs simply don’t have the funding, rules framework or technology to comply with Final Rule requirements, including continued reliance on data segmentation. So while in theory the rule is technologically viable, in the real world the result will be extremely serious:  In all probability the easiest way for most HIEs to respond to the new rule will be to continue to refuse to accept data from patients whose health records include SUD data subject to 42 CFR Part 2 protections, thus barring them from receiving the higher quality of care we are striving for as a nation.


We believe that SAMHSA’s ability to update privacy and consent regulations is constrained by the existing statutes. To overcome this problem, Netsmart will advocate in Congress for statutory changes to better enable needed changes and attain healthcare parity for this at-risk population and the providers who serve them.

Integrating Care: Moving Beyond Interoperability to True Collaboration, Part II


Building the vehicle which will take us beyond interoperability to full integration is a complex task. But, as we saw in the first blog post in this series, there’s ample proof that the need is great – longevity is threatened without integration, quality of life is diminished and costs are needlessly driven higher. So, what does integration look like in practice? Continue reading Integrating Care: Moving Beyond Interoperability to True Collaboration, Part II

Integrating Care: Moving Beyond Interoperability to True Collaboration, Part I

It’s something every traveler knows — you can’t get to where you want to be if you don’t know where you are. For the purposes of this blog series, our collective goal is to arrive at a place of integrated care where behavioral health and human services connect to acute and primary care, providing a single patient/provider view across the entire care continuum. We know we want to arrive at this place because we’ve seen the facts. Let’s refresh them now.

Severe mental illness (SMI) has a direct impact on lifespan. Continue reading Integrating Care: Moving Beyond Interoperability to True Collaboration, Part I