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

Progress… The Anna Westin Act Passes

tom_h_info-picI want to pause for a moment, to recognize the historical impact of yesterday’s passing of the 21st Century Cures and Mental Health Reform Act of 2016, including key provisions from the Anna Westin Act of 2015. Those of us at Netsmart are fortunate to know Anna’s family and have had the opportunity to help tell their story over the last few years. Anna’s mother, Kitty Westin, spoke at our 2015 Connections and reminded us of the importance of the mission linking us all.

Eating disorders are marked by extreme physical and emotional suffering. Someone with an eating disorder experiences severe disturbances in their behavior while exerting a super human amount of will in an attempt to control their eating. They may eat only small amounts of food, they may eat uncontrollably, or some may alternate between unhealthy periods of fasting followed by bingeing.

The psychological stress they experience related to eating affects every aspect of their lives and the lives of their loved ones. The triggers are different for each person and often unknown, yet reflective of a deep, visceral pain. Eating disorders are indeed illnesses of both the body and the mind. Perhaps nothing describes the internal struggle better than the following journal entry.

“I am scared to death about what’s going on right now. I can’t have any control over my own mind. As much as I know what I need to do it’s so hard to. My moods are very extreme. One minute I’ll be depressed, then another, something will make me happy again.”

Those were the words of Anna Selina Westin. She was a natural beauty of just 19 years when she wrote them. Outwardly, she was a caring young woman, conscientious and generous with her time. She was a joy to be around and by all accounts, she absolutely “sparkled.” Inwardly, however, she struggled mightily. For years she hid the uncontrollable urge to deprive herself of the nutrition her body so desperately needed. There were obstacles that prevented her from receiving the psychological treatment she needed. Kitty Westin, describes the helplessness she felt after being denied by Anna’s insurance.

The insurance company, who had never talked to Anna, had never seen her, didn’t really know anything about her, said that it wasn’t medically necessary, which is obscene. It makes me very, very angry. Anna had a disease they didn’t want to even hear about.

In 2000, after a five-year struggle with the very real medical condition of Anorexia Nervosa, Anna Westin took her own life. She was only 21-years-old.

Fortunately, Anna’s story does not end there. Just as in life, her legacy will be to help others. On Dec. 7, 2016, Congress passed The 21st Century Cures Act. Within that piece of legislation was The Anna Westin Act of 2015.

This bill, introduced by Senator Amy Jean Klobuchar, D-Minn., is the first to address eating disorders specifically. It included the following provisions:

The Office on Women’s Health, a division of the Department of Health and Human Services revise both the BodyWise Handbook and BodyWorks obesity prevention program to include specific information about eating disorders related to both males and females.

– The Substance Abuse and Mental Health Services Administration award the following grants:

  1. To update and merge training on eating disorders into the existing curriculum for health, public health and mental health professionals.
  2. To states, educational institutions and Indian tribal organizations for seminars geared toward school personnel on eating disorders.
  3. To allocate available resources to individuals suffering from eating disorders.
  • The National Institute of Mental Health must make PSAs on eating disorders.
  • Amends the Public Health Service Act, ERISA and IRC –prohibiting them from permanently excluding any particular condition from being deemed eligible for mental health or substance use disorder benefits, including inpatient treatment.

Mental health professionals agree that training and early recognition by healthcare providers is key to saving lives. Removing the roadblocks that Anna and her family faced in receiving appropriate and timely residential treatment is a huge win for the millions of individuals currently diagnosed with an eating disorder as well as those who are suffering in silence.

The Facts on Eating Disorders – According to the National Eating Disorders Association

– Eating disorders affect around 20 million women and 10 million men in the U.S. currently.

– Struggles with negative body image and body dysmorphic disorder are some of the earliest warnings signs.

– Depression and other mood and personality disorders frequently occur with eating disorders.

– Despite the serious statistics, eating disorders continue to receive inadequate funds for research.

– 42 percent of girls in 1st-3rd grade wish they were thinner.

– 81 percent of 10-year-old girls are afraid of becoming fat.

– In individuals diagnosed with anorexia nervosa, suicide is the second leading cause of death (after cardiac disease) and a major cause of death among people with any other eating disorder

There will never be a moment in which you are not you. Some may try to hide their existence away, pretending they are someone they’re not, but who is this act for? You know the ultimate truth, there is no hiding from yourself. The difficulty of it lies in our societies’ ability to create perfect illusions. – Anna Westin 

To learn more about the life and legacy of Anna Westin, as well as the journey that took her parents Mark and Kitty from grief to advocacy, visit our non-profit advocacy foundation, Every Day Matters and view the documentary A Journey of Love: The Anna Westin Story. 

If you are worried that you may have an eating disorder and need help; or if someone you love is exhibiting signs of an eating disorder — we invite you to visit our Support Resources page to learn more information about eating disorders.

If you are thinking about suicide or just need someone to talk to about your eating disorder or any other mental or physical problem, please do not delay and call the National Suicide prevention Lifeline: 1.800.273.TALK (8255) immediately.

Lastly, I encourage all of us to consider becoming Mental Health First Aid certified. This course both informs and equips around essential fundamentals, providing tools to aid when need arises. Earlier this year I completed my certification, grateful as I was prepared to better assist and offer help in a recent conversation.

If we are willing, intentional in thought and deed, we have the opportunity to ensure Every Day Matters as we serve in pursuit of awareness, assistance, wellness and recovery.

So yes…goodness happened yesterday, progress indeed, but we have more work to do!

#Cures #CuresAct #CuresNow #MentalHealthReform #MHFA #1in1m #CauseConnected #healthcare

Throwing Out the Cookie Cutter: Understanding and Embracing Person-Centered Care


A curious term is increasingly being used in the intellectual and developmental disabilities (IDD) community. It’s person-centered care. I say it’s curious because it naturally prompts the question, “hasn’t care always been centered on the person?” The answer to that question is “well, not exactly.” Allow me to explain. Continue reading Throwing Out the Cookie Cutter: Understanding and Embracing Person-Centered Care

People are the Key to True Care Integration

mary_gannon_info_picThe word integration is so prevalent in healthcare it has become a cliché. Google the term “healthcare integration” and you’ll get more than 76 million results! But integration is typically discussed solely within the context of technology. True integration is a coordination of processes or “a bringing together.” I don’t know about you, but when I think of togetherness I think of people. It’s through togetherness that people create and optimize processes and – at that point – use technology to maximize efficiencies.

On October 23rd I’ll be leading the CONNECTIONS 2016 Nursing Summit. Nurses from across the country will hear from speakers about the intersection of nursing and technology, but, more than that, we’ll be sharing experiences, ideas and, yes, challenges we’re facing. Nurses are among the most engaged groups in the care process and the use of technology to improve outcomes. It’s nurses who spend the majority of time inside electronic health records (EHR). It only makes sense that we come together in a roundtable setting to share insights. That’s integration.

You’ll notice I’m using the word “we.” I, too, am a nurse (who happens to be an EHR product manager). Many of my colleagues at Netsmart, including Dr. Dennis Morrison and Dr. Ian Chuang, also have clinical backgrounds. That’s not a coincidence – it’s by design. Our goal is to help improve outcomes, so it’s important to have an immersive understanding of what’s happening on the front lines of care. Likewise, it’s key that those on the front lines of care have a full view of the technological options to optimize care. That’s integration.

I can’t wait for our Nursing Summit at CONNECTIONS 2016. We’ll examine everything from value-based payment models to innovations to the future of care management. But I think the biggest breakthroughs will come from engaging with each other, sharing our successes and struggles face-to-face. Through those transparent discussions we can coordinate processes and come together to improve outcomes. That’s integration.

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