Major strides forward are being made at the Behavioral Health Information Network of Arizona (BHINAZ), a behavioral health information network (HIE) owned by community providers in Arizona. BHINAZ specializes in the exchange of data, both physical and behavioral health data. “We’ve been focused on a pretty robust consent model and the exchange of data, and making sure that our providers can get the data they need for the services they provide,” says Laura Young, BHINA’s executive director. Recently, says Young, “We’ve been really focused on our crisis project, which entails getting providers who are involved in caring for seriously mentally ill (SMI) individuals through clinic-based care, involved, and providing information to crisis hotlines, first responders, mobile teams.”
In April 2015, Young gave an interview to HCI Managing Editor Rajiv Leventhal about the creation of the Behavioral Health Information Network of Arizona. “In Arizona and in other states, we have Regional Behavioral Health Authorities (RBHAs),” she noted, “and in Maricopa County, where I live, the RBHA contract of $7 billion over five years—for behavioral health services passed out from federal funds to the state and then out to designated behavioral health agencies— was up for bid. In the past, the challenge has been when those agencies lose those contracts, they pack up their data with them, so there are issues with continuity of care and being able to access information about patients and clients. There was a feeling that the way to go was start working on an HIE for behavioral health.”
In that interview, Young added, “So the HIE is stakeholder-owned, comprised of seven nonprofit organizations. It’s very much at the community level, driven by behavioral and community health providers. Our approach comes from the bottom up rather than top down, so we are able to be at provider level and insert the HIE directly into the practice and do workflow and training right at the organizational level.”
Young, who participated as a panelist recently on a panel entitled “Interoperability & HIE: Strategies for an Evolving Health System,” at the Health IT Summit in San Diego, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics, under the Vendome Group corporate umbrella), spoke recently with HCI Editor-in-Chief Mark Hagland regarding the current initiatives taking place at BHINAZ. Below are excerpts from that interview.
You referenced at the Health IT Summit in Miami that your organization has been focusing strongly on health information exchange in crisis mental healthcare situations. Is consent an issue in such situations?
Consent actually doesn’t really apply around these situations, because they involve genuine crises, such as potential suicide situations, for example. And a crisis hotline might do a little bit of triage such a situation. But if the patient seems genuinely in crisis, the hotline can look up information on the portal, see if they’re a danger to themselves or others, find out if they’re voluntarily in treatment or involuntarily court-ordered into treatment, per a criminal proceeding, for example. We worked with a consortium of providers, and they needed to see that element. So we actually had to retrofit our HIE, to add in additional pieces of information around whether people are a danger to themselves, to others, or “SMI”—seriously mentally ill. That’s a designation that comes usually from the Medicaid managed care company. When that designation occurs, regional behavioral health authorities, or RBHAs, pick up the spend both for physical and behavioral health for patients who are on Medicaid. So if they get that designation, everything is paid for. And once they’ve been given that designation, you’re always considered SMI.
So the crisis providers want to know those pieces of information. They also want to see information on contacts. And who their guardian is—that might be different from a family member, for example, there might be a designee from a court who is the guardian.
So you’ve standardized a data set for such situations?
Yes, so when we connect people, we say, these are the pieces of data needed. It’s an extra 11 data elements that our crisis providers wanted. So, things like injectibles—when you’re given a prescription for methadone treatment, you might be prescribed methadone, but in the medication module, they’re not always documenting the administration of methadone, there might be a documentation of a one-time prescription. But on the phone, they’ll want to know when the last time the person got the injection. And it turns out that isn’t always standardized. So we work really hard to standardize that and bring it forward as a data element. And providers in a non-emergency setting might want that information with consent also.
This process went just went live in early January. We had been working on it for six months, and we had the providers connected, and this month, crisis call lines, mobile teams, psychiatric urgent care centers—some of the organizations we don’t have yet, still, are jails, and we want to do some pilots in the emergency departments also. Because a lot of these folks hit the ED a lot. One person had hit the ED 50 times in a month. So if we can incorporate their data, a lot of times, they can get to more suitable care settings. Sometimes the ED isn’t the appropriate place for psychiatric care. Yet a lot of times, they end up just sitting in an ED for 72 hours and then get discharged. The other piece of this that’s really crucial is that whenever our patients do engage with our crisis system, an alert goes out to their treating provider, if they’ve contacted crisis service providers or EDs. So we get the case managers involved early, so they can get them into less highly acute locations for care, and also engage them so they’re not going back to the ED for care the next time. So the crisis emergency management system we’ve designed, now we’re helping others implement, as consultants.
This is also a great point for getting into behavioral health exchange, because the consent piece doesn’t even have to be implemented.
How many parties have been connected so far?
We have two organizations connected right now, and one is a crisis center organization. We’re working to connect six crisis center organizations in total. They all do slightly different services, but all provide some sort of crisis management.
When will all six will be online?
Within the next two months. We should be live with three by the end of the month [January].
What has been the hardest part of doing this?
The initial piece involved understanding the data elements required. We had to have a bunch of meetings with the crisis providers, and sometimes, they wanted too many elements, so narrowing it down was a challenge; so was figuring out where this data was residing in the EHRs. So finding the information was one of the bigger challenges. And once we get it into their hands, they’re really excited about it. So adoption is not an issue, but if the data isn’t what they want, they won’t use it.
So this is the first of its kind in the country?
It probably is; from an HIE perspective, some managed care companies probably have some version of this for their members. But it surprises me to learn that a lot of areas don’t even have coordinated crisis services. A lot of other states are using EMS or other providers to deliver services. I’m finding that it really varies by market. But this is a system that could work in a market that uses EMS services, too; we could roll it as a portal. Or it could help some markets expand crisis services. And Bernalillo County and the City of Albuquerque came out to visit us, and we then visited them. And neither had implemented crisis services in this way.
What have been the couple of biggest learnings in this so far?
They’re related to those challenges, but I would say from a best-practices perspective, it’s really important to get the providers to the table to get their feedback and input. You get more buy-in that way. So, as a whole, for HIE, involving the providers—we get a lot more utilization and adoption from providers when we get their buy-in. And that may seem obvious. But… From an HIE perspective, HIEs are very hard to sustain, so financially, it makes sense to try to get the big payers and providers involved from the beginning. But then you don’t necessarily get the grassroots participation. So we started at the grassroots, but from a financially perspective, we were slower to get buy-in from the biggest organizations. So it’s a pros-and-cons kind of thing, and that’s probably why a lot of organizations start at the top, but I think that getting that provider input and participation from the beginning is key, because a lot of HIEs flounder as a result.
Do you have anything else you’d like to add?
We’re working really hard to get behavioral health integrated more into HIE in general, not just in Arizona. There’s a big need for it. We’re seeing a big push for that across the country. We’ve had some people reach out to us, and now we’re reaching out as well. We’re excited to be part of that initiative, and to see where we can take it.