Last April, two health IT vendors—the Horsham, Pa.-based NextGen Healthcare Information Systems and its sister company, Mirth, based in Costa Mesa, Calif.—announced the launch of the Behavioral Health Information Network of Arizona (BHINAZ), publicized by its officials as the first statewide behavioral health information exchange (HIE) in the nation.
BHINAZ was the brainchild of a consortium of behavioral health providers who are customers of Topaz Information Solutions, an authorized NextGen reseller and outsource partner that specializes in behavioral health and social services. Topaz, in partnership with NextGen Healthcare, built specific content within the technology platform to meet specific needs of behavioral health and social services organizations.
Leveraging NextGen’s ambulatory electronic health record (EHR) and HIE, and Mirth Connect— an open source application used for healthcare data integrations—BHINAZ created the legal and operational framework necessary to protect confidentiality while helping to facilitate data exchange and streamline the process for behavioral health providers to obtain and manage patient consent, specifically as it relates to exchanging patient information, officials say. As a result, BHINAZ will provide clinicians throughout the state with a longitudinal patient history at the point of care, making information available when and where it's needed for medical care.
Shortly after the announcement, HCI Senior Contributing Editor David Raths interviewed Laura Young, the executive director of BHINAZ, about the network’s goals and progresses for HCI’s sister publication, Behavioral Healthcare. At that time, the organization was just getting off the ground, with some of the main challenges being around legal and privacy issues with patient consent, as well as connecting to the physical health HIE in Arizona, and of course, cost.
Operating under an “opt-in” consent management model, BHINAZ said that it will ensure that data protected under Federal Law 42 CFR Part 2 is not re-disclosed without proper consent. Within the NextGen EHR, customized behavioral health consent management templates were created by working collaboratively with BHINAZ to include required content management language and capture electronic signatures at the point of care. Using these templates, information is sent to the NextGen HIE, which then dictates specifically what data a given provider can access within the EHR. Patients and clients have the option to choose if they would like their data to be shared with the rest of the closed network at each BHINAZ location. Last year, Young told Raths that, “It really is all or nothing. We are treating all of the data within our HIE as protected 42 CFR Part 2 data. If the client isn’t comfortable sharing their Part 2 data, then we aren’t going to share anything else.”
A year later, HCI Associate Editor Rajiv Leventhal checked in with Young, and the challenges for BHINAZ remain similar to what they were in 2014. Below are excerpts of that recent interview.
Tell me about the logistics behind the creation of BHINAZ?
In Arizona and in other states, we have Regional Behavioral Health Authorities (RBHAs)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.
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.
How is it being funded?
Initially, the money didn’t come from the RHBAs, but that where it’s gone towards now. We do have a subscription model, and when we connect providers, there’s a connection fee with a sliding scale for monthly subscriptions. In working with the RHBAs, and there are now three of them in Arizona, their contracts obligate them to have some sort of HIE technology, and they’re also obligated to do integrated care, for both physical and behavioral health. So it’s turned into a critical thing for them to work with us. We’re contracting with them to connect providers, and they’re covering the cost of connection in exchange. We want providers to put some sort of money into it, otherwise they don’t own the technology and are less inclined to use it to be honest. We are also working on initiatives at the state level to get allocations that would go to our HIE and the physical health HIE in the state.
To what extent has your network grown, and how many organizations are exchanging data?
We have about eight providers, not necessarily the stakeholders which is ironic since it’s around the same number. We have also partnered with Quest Diagnostics, and now we have providers ordering in results and labs through the HIE. We’re right at that threshold where we'll connect more providers. There are about 200-300 behavioral health providers statewide, and of that, 40 or 50 of them touch 90 percent of the participants, so we are working on getting those providers on board first.
Has the lack of meaningful use incentive dollars hampered things at all?
One of the barriers is definitely lack of good EHR technology. In behavioral health, there are a lot of mom-and-pop applications. The other barrier is that a lot of these vendors charge a fortune for interfaces—thy either charge per interface or charge a lot at one time to give you an HL7 channel for instance. That makes it cost prohibitive for some of these providers, especially the smaller ones. The vendor cost for their EHR is sometimes the barrier to getting connected. The EHR companies are also trying to bite a piece off the HIE business, so they compete against HIEs, which I think slows everyone down. More collaboration is needed.
How has that experience been, connecting to the physical health HIE in the state?
We’re finishing up a connection from them so we will have all the hospital admits and discharges, and we can rout those in real time to our providers. A lot of the time these behavioral health patients get admitted in hospital or go to the ER, and they stay for 72 hours which is the requirement, but they don’t necessarily get a lot of treatment during that time. They might get discharged without addressing their concerns. Sometimes there are no follow-ups, and this way with alerts, intervention and coordination becomes critical.
Working with them has been a good partnership, I’d say. Our approaches are different, they have an opt-out model, we have an opt-in one. Their main focus has been around connections, getting big hospitals and payers on board and connected. They don’t spend much time at the community level doing workflow, so we do have different approaches. But we do also need each other, and we try to work together on things as the long-term goal is bi-directional exchange so the behavioral health data is getting back to the physical health providers. That will take some work.
How does your opt-in model work specifically with behavioral health patients?
We require explicit consent. For our model, the education piece is especially important. We spend time on educating the provider on educating the patient. We have about a 78 percent opt-in rate, but it does vary by type of provider, and when that consent is presented varies too. For example, if you’re coming into a detox center you won’t be presented with the consent right away. We have had good success with it though. If we convince the patients that the HIE is good for them, that they don’t have to repeat things every time they go to another provider, it will help them understand why it’s really best to opt-in. We want to improve that rate and do more education, but we are happy with our success so far.
Consent has also taken up a big chunk of our time. We spent 18 months doing legal and technical work on consent. In fact, we have done so much work on it that we have become the de facto expert on it. We actually get calls on how we do it. A lot of groups see things that go into consent requirements for behavioral health and want to figure it out later. I mean it took us a year and a half, that’s all our organization was doing. Imagine if you had a lot of other priorities?
Are there other HIEs in this space who you’re competing against?
We are the only standalone behavioral health HIE in the country. Other states are doing behavioral health as a component, but some of it is just using Direct exchange point-to-point, not a full blown repository. Colorado, Kansas, Rhode Island are states that do have behavioral health in their exchanges, but it’s hard for me to say what it looks like or what’s being exchanged. So there is no competition from that perspective.
Is behavioral health data exchange any different than physical health exchange?
One of the big areas of focus for us is crisis services. In a crisis, time is of the essence, so being able to have as much data as possible available about someone is critical. The type of data isn’t your standard data set, though. Rather than radiology and labs you’re looking for documents, assessments, and treatment plans. That’s where I see a bigger difference between physical health and behavioral health data exchange. And it’s not that they don’t exchange documents, but they are looking for diagnostic types of data versus these comprehensive documents. That’s where we insert ourselves and try to get people off paper. It’s such an old process, faxing and scanning compared to embedding right into the EHR.
What are some key goals for BHINAZ in the next year or so?
A lot of what we do is dictated by our participants; the RHBAs have a priority list, so we work that direction. We are also really focused on crisis services; it’s at the top of our list. We are working on a consolidated crisis viewer, which is different than what you’d see in a standard HIE, as there are very specific data elements that you need to see for crisis. Right now folks are looking in seven different systems, and in crisis, that’s not efficient as you can imagine.
Also around crisis, we are improving our call centers. It’s a very old-fashioned process right now, so we are building a connection from the call center to the HIE that would rout a crisis call to the mobile team as a direct referral, and they would be able to pull that directly into the EHR. An added benefit of that is if there happens to be patient match, and in crisis that’s not easy because patients don’t always give their real names, we can pick up any other HIE data that we might have that they didn’t relay on the phone call. The team can then document that back in the EHR, and close that loop back to the call center.