Encouraging Health Information Technology Adoption in Behavioral

Chapter 4:

Encouraging

Health Information

Technology

Adoption in

Behavioral Health:

Recommendations

for Action

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

Encouraging Health Information

Technology Adoption in Behavioral Health:

Recommendations for Action

Recommendations

4.1 The Secretary of the U.S. Department of Health and Human Services should direct the Centers for

Medicare & Medicaid Services, the Substance Abuse and Mental Health Services Administration,

and the Oce of the National Coordinator for Health Information Technology to develop joint

guidance on how states can use Medicaid authorities and other federal resources to promote

behavioral health information technology adoption and interoperability.

4.2 The Secretary of the U.S. Department of Health and Human Services should direct the Substance

Abuse and Mental Health Services Administration and the Oce of the National Coordinator for

Health Information Technology to jointly develop a voluntary certication for behavioral health

information technology.

Key Points

•

Delivery systems for physical and behavioral health are often fragmented. This impedes access to

care and results in inappropriate or limited use of services, poor health status, and increased costs

for persons with behavioral health conditions.

•

Adoption of certied health information technology (IT) is one strategy to promote integration.

Health IT can improve communication between providers and allow them to electronically retrieve

and transfer patient information in real-time.

•

Behavioral health providers have adopted IT at lower rates compared with other providers because

they were not eligible for federal incentive payments. Current barriers to adoption include the costs

of technology and training, challenges related to sharing information about substance use disorder

(SUD), and the lack of industry guidelines for behavioral health IT.

•

Medicaid programs play a critical role in nancing behavioral health services and are increasingly

focusing on ways to provide behavioral health in more integrated settings.

•

Additional subregulatory guidance is needed on how Medicaid and State Children’s Health

Insurance Program (CHIP) authorities can be used to encourage health IT adoption for behavioral

health providers.

•

At the federal level, the Oce of the National Coordinator for Health IT (ONC) is charged with

providing health IT guidance by developing informational resources that guide providers and

developers when implementing health IT for specic settings of care and medical specialties.

•

To help providers in the purchase of health IT and to move the market toward better products

for behavioral health practice settings, the Substance Abuse and Mental Health Services

Administration and ONC should jointly develop a voluntary certication for IT used in behavioral

health and integrated care settings to support ongoing integration efforts.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

CHAPTER 4:

Encouraging

Health Information

Technology Adoption

in Behavioral Health:

Recommendations

for Action

Over the years, the Commission has discussed

at length the need to improve integration of care

for Medicaid beneciaries with behavioral health

conditions (MACPAC 2021a, 2018, 2017, 2016).

The delivery systems for physical and behavioral

health care, which encompass practitioners

who treat substance use disorder (SUD), mental

health conditions, or both, are not integrated with

each other. Furthermore, delivery systems for

mental health and SUD are also fragmented. In

addition, behavioral health treatment is not well

coordinated or integrated with treatment for other

physical health conditions (MACPAC 2018). This

fragmentation impedes access to care and may

result in inappropriate or limited use of services,

poor health status, and increased health care costs,

particularly for persons with behavioral health and

chronic health conditions.

Integrating care potentially can improve overall

care and reduce spending. Integrating care is of

particular concern to the Medicaid program given

that its beneciaries have higher rates of SUD and

mental health conditions and have higher rates

of other chronic conditions than their privately

insured peers (MACPAC 2021a and 2021b).

Medicaid is the largest payer of behavioral health

services in the United States due to the population

it covers and the services it nances.

State Medicaid agencies can play an important role

in supporting the integration of care for individuals

with behavioral health needs. In our June 2021

report, we focused on one barrier to integration:

the relatively low rates of electronic health records

(EHR) and information technology (IT) use among

behavioral health providers. The report showed

most behavioral health providers were ineligible

for federal incentives for EHR adoption under the

Health Information Technology for Economic and

Clinical Health Act of 2009 (HITECH, P.L. 111-5) and

documented the low rates of use of these tools

among behavioral health providers, particularly

relative to the sharp uptick in EHR use among other

providers as a result of HITECH (Wolf et al. 2012).

This year, the Commission focused on policy

options to strengthen Medicaid’s role in

encouraging behavioral health providers to adopt

health IT. We considered a range of strategies and

sought feedback on their merits from state and

federal ocials, providers, IT vendors, and other

experts in the eld. In this chapter, we make two

recommendations to promote greater use of health

IT, which should improve integration of care:

•

The Secretary of the U.S. Department of

Health and Human Services should direct the

Centers for Medicare & Medicaid Services, the

Substance Abuse and Mental Health Services

Administration, and the Oce of the National

Coordinator for Health IT to develop joint

guidance on how states can use Medicaid

authorities and other federal resources to

promote behavioral health IT adoption and

interoperability.

•

The Secretary of the U.S. Department of

Health and Human Services should direct the

Substance Abuse and Mental Health Services

Administration and the Oce of the National

Coordinator for Health IT to jointly develop a

voluntary certication for behavioral health IT.

Guidance on how to deploy existing authorities

and federal funding opportunities would help

states identify approaches for advancing the

adoption and use of health IT for behavioral

health providers, furthering integrated care efforts

among state Medicaid agencies. In addition, the

development of a voluntary certication for IT

appropriate for behavioral health and integrated

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

care practice settings could provide a path toward

comprehensive adoption of high-quality behavioral

health IT tools, ensuring real-time data sharing and

collaboration between behavioral health providers

and virtually all hospitals and physicians.

This chapter begins by reviewing the implications

of poorly integrated care for behavioral health

and outlining how health IT can foster more

integrated care through patient data sharing.

Next, the major barriers to EHR adoption in

behavioral health are described. The chapter

concludes with recommendations to address

Medicaid’s role in supporting health IT adoption

and state care integration efforts, noting that

Medicaid authorities could be used to promote

behavioral health IT adoption and could be

deployed more effectively with improved guidance

and instructions from the Centers for Medicare &

Medicaid Services (CMS). We also note the need

for federal actions to provide clarity regarding

health IT standards and functions in EHRs to

facilitate behavioral health integration (Box 4-1).

Benets of Clinical

Integration and Health

Information Technology

As noted above, Medicaid beneciaries have higher

rates of mental health conditions and SUD and

experience other chronic conditions at higher rates

than their privately insured peers (MACPAC 2021a

and 2021b).

Individuals with mental illness have

worse health outcomes and die 32 years earlier

when compared to the general population (Roberts

et al. 2017, NASMHPD 2012). The COVID-19

public health emergency has underscored these

vulnerabilities, as persons with mental health

conditions and SUD face even greater mortality

and morbidity risks due to COVID-19 (Fond et al.

2021, Das Munshi et al. 2021, Wang et al. 2020).

Additionally, MACPAC has found there are signicant

disparities in unmet need for behavioral health

services; beneciaries with a mental illness who

identify as Black, Hispanic, or Asian American

receive treatment at lower rates compared to those

that identify as white (MACPAC 2021b).

Greater sharing of clinical information between

behavioral and physical health providers can

improve care among adults with mental illness.

(Gilmer et al. 2016, NASEM 2020, PCC 2022).

For example, when providers are unable to share

information about their patients, gaps in knowledge

may lead to conicting treatments, such as

prescribing medications with potentially dangerous

or even deadly interactions with other medications

(MACPAC 2018).

EHRs can foster clinical integration through

data sharing, care coordination, and referral to

treatment across the continuum of care (MACPAC

2021a). They can promote coordinated care by

allowing clinicians to readily update patient health

information and distribute that information to

authorized providers working in other settings

(Falconer et al. 2018). While EHRs on their own

do not integrate patient care, the ability to share

information among providers and between providers

and patients is an important step toward this goal.

Increased provider adoption of certied health IT

and certied EHR technology is one strategy to

improve integration of care.

Certied health IT

improves communication between providers and

allows them to electronically retrieve and transfer

patient information, often in real-time. However, the

costs associated with certied EHR technology and

the unique needs of behavioral health providers

represent signicant barriers to adoption with

only 6 percent of mental health facilities and 29

percent of substance use treatment centers using

an EHR, compared to more than 80 percent of

hospitals (MACPAC 2021a, ONC 2017, Henry et al.

2016). Behavioral health providers are thus less

likely to send and receive patient information with

those providing other health services and many

continue to rely on phone, paper, or fax. This can

lead to missed opportunities to provide integrated

services and improve quality of care for Medicaid

beneciaries.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

The Commission previously has noted the benets

of certied EHR technology adoption in behavioral

health integration efforts, and the extent to which

health IT addresses other issues of concern. Namely,

certied EHR technology facilitates:

•

connections to state health information

exchanges (HIE);

•

participation in value-based arrangements; and

•

provider data submissions that are necessary

for the state to calculate quality measures

in the Medicaid Adult and Child Core Sets

(MACPAC 2021a, MACPAC 2020c).

Barriers to Certied Health IT

Adoption Among Behavioral

Health Providers

The barriers to certied health IT and certied EHR

technology adoption are multifaceted but mainly

fall into three areas, including the signicant

cost implications of EHR adoption, the unique

challenge associated with SUD privacy protection

outlined under 42 CFR Part 2 (Part 2), and the lack

of clear guidelines to ensure that health IT tools

can meet the needs required in behavioral health

practice settings.

BOX 4-1. Key Health Information Technology (IT) Terms

Standards: The common language and common set of expectations that enable different systems

to interact with each other. Standards permit clinicians, labs, facilities, and patients to share

data regardless of the application or market supplier (HIMMS 2022). The Oce of the National

Coordinator for Health Information Technology (ONC) is responsible for updating standards and

specications to support interoperability and different health information exchange scenarios.

These standards are outlined in the Interoperable Standards Advisory (ISA) (ONC 2019a).

Function: Specic capabilities that an electronic health record (EHR) or an IT system should

possess to document and share patient care. Examples include providing immediate access to

health information and data; giving patients access to their health records; data storage that is

amenable to federal, state, and private reporting; and clinical decision support tools (IOM 2003).

Interoperability: The ability of different information systems, devices, and applications to

access, exchange, integrate, and cooperatively use data in a coordinated manner, within and

across organizational and geographic boundaries, to provide timely and seamless portability of

information and improve the health of individuals and populations (HIMMS 2022).

The 21st Century Cures Act (Cures Act, P.L. 114-255) also created a statutory denition for

interoperability that states that health IT is interoperable when it:

•

enables the secure exchange of electronic health information with, and use of electronic

health information from, other health information technology without special effort on the part

of the user;

•

allows for complete access, exchange, and use of all electronically accessible health

information for authorized use under applicable state or federal law; and

•

does not constitute information blocking.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

Costs

Behavioral health providers report that the cost

of purchasing, installing, and training staff is

the principal barrier to certied health IT uptake

(NASMHPD 2018).

Such costs are signicant,

especially for solo practitioners and those in small

practices as well as for state behavioral health

agencies with limited budgets (NASMHPD 2018).

Many hospitals and physicians received federal

incentive payments for EHR adoption under the

HITECH Act, and could be eligible for almost $64,000

over a six-year period per individual eligible provider,

and almost $15 million over a four-year period for

eligible hospitals.

Behavioral health providers and

facilities, with the exception of physicians and some

nurse practitioners, were not included in this effort.

Due to narrow operating margins, behavioral health

providers often have little capital available to invest

in the expensive hardware, software, and training

needed to use EHRs (MACPAC 2016). The COVID-19

pandemic has further strained provider nances

despite increased demand for services. Furthermore,

a national crisis hotline will be implemented in 2022,

which may further increase demand for behavioral

health services across the care continuum (NAMI

2021, Eder 2022, MACPAC 2021b). The National

Council for Mental Wellbeing’s April 2021 survey

found that 40 percent of behavioral health

organizations only can maintain their operations for

a year due to nancial issues (NCMW 2021).

In addition to the costs of the technology itself,

there are signicant costs associated with training

providers to meaningfully use an EHR and high

demand for technical assistance. For many

behavioral health providers, sharing information

electronically will require major shifts in how

they operate, for example, adopting new practice

workows that integrate technology (AmeriHealth

Caritas 2021, Covered California 2021, NYeC 2021).

Addressing the privacy-related concerns related to

sharing information about SUD data protected by

Part 2 also may create additional costs, as providers

may need to establish how to share these records

and hire legal counsel to update privacy practice

notications and disclosure and redisclosure

consent documentation (OHA 2021).

SUD patient information

Another key challenge for providers is segmenting,

or restricting access to SUD information, while

sharing the rest of the patient record. Federal

health IT certication requirements were designed

to support compliance with the Health Insurance

Portability and Accountability Act of 1996 (HIPAA,

P.L. 104-191) and its implementing regulations

(45 CFR Part 160 and Part 164, subparts A and E),

which govern the use and disclosure of individually

identiable health information (i.e., information

related to all health conditions, health care services,

or payment) (Box 4-2).

HIPAA generally allows

information to be shared without patient consent

among providers and payers for payment, treatment,

and health care operational purposes.

Certied

health IT provides assurances that the product

supports compliance with HIPAA and allows for the

seamless sharing of patient records.

In contrast, SUD treatment information created,

received, or acquired by Part 2-covered providers

is subject to additional requirements that affect

information sharing among providers. Specically,

Part 2 does not allow for the disclosure or

redisclosure of protected SUD information for

treatment purposes from Part 2-covered providers

without written consent from the patient. This

protection overrides the HIPAA information sharing

provision. As such, Part 2-covered providers must

obtain patient consent to disclose and redisclose

such records, including for care coordination

and case management.

To support compliance

with Part 2, health IT must be able to segment

Part 2-protected SUD treatment information from

the rest of a patient’s health record.

While data

tagging and segmentation capabilities have been

developed, they have not been widely incorporated

into certied EHR technology used by many

Medicaid-enrolled providers.

Changes in federal privacy laws may make it

easier for providers to share this information. The

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

Coronavirus Aid, Relief, and Economic Security Act

(CARES Act, P.L. 116-136) aligned the statutory

basis for Part 2 more closely with HIPAA. Among

other things, it permits providers to obtain a single

patient consent for all future disclosures of SUD

records for treatment, payment, and health care

operations. The CARES Act allows Part 2-covered

entities and business associates that receive Part 2

records to redisclose it in accordance with HIPAA.

Under HIPAA and Part 2, patients have the right to

request a restriction on the use of SUD records for

treatment, payment, or health care operations, and

the CARES Act requires Part 2-covered providers

to make every reasonable effort to comply with a

patient’s request.

Although the CARES Act takes steps to advance

data sharing among SUD treatment providers, EHRs

and connected information exchanges used by

behavioral health providers will continue to require

data segmentation capabilities because individuals

still can request restrictions on use of their

treatment records. Moreover, in addition to being

subject to HIPAA, other sensitive health data (e.g.,

related to HIV/AIDS, mental health, substance use,

reproductive health, and domestic violence) also

may be subject to state laws or other federal laws

mandating heightened disclosure or redisclosure

protections (OCR 2017). For this reason, it is

essential for IT in settings where behavioral health

services are provided to have standards that

support consent management, security labeling,

and segmentation for access, exchange and use of

health information at a document, section, or data

element level.

Lack of clear guidelines for behavioral

health IT

The HITECH Medicaid EHR adoption incentives

spurred a large and active vendor market, especially

for oce-based practices (Gold 2016).

This

allowed providers to choose an EHR that was

affordable and met their specic clinical needs.

However, there were drawbacks. Due to the

extensive choice of products available, it took an

informed provider to purchase the right EHR for a

specic practice. In some cases, providers chose

EHRs that met their initial needs but later turned

out to be insucient for subsequent reporting

needs (Gold 2016). To partially address this, the

21st Century Cures Act (Cures Act, P.L. 114-255)

was passed in 2016 to give the U.S. Department of

Health and Human Services (HHS) more authority in

limiting the spread of EHRs and health IT that block

information sharing (Lye et al. 2018).

Currently, voluntary certications for IT exist for

other practice settings (e.g., pediatric practices),

but not for behavioral health. Based on a set

of specically appropriate criteria, a voluntary

certication from ONC would help behavioral health

providers understand what to look for in an EHR

and also send a signal to the market that certain

features are desirable for behavioral health practice

settings (Box 4-2). As noted above, behavioral

health providers need different privacy and clinical

tools within their EHR compared to physical health

providers, functions that may not be supported

by many EHRs certied based on the current ONC

health IT certication criteria. For example, these

include Part 2-related segmentation capabilities

and capturing standardized information about plans

of care, encounter notes, or patient-directed goals.

Although some currently available behavioral health

IT may have some of these functions, they may not

capture this information in a way that promotes

interoperability and supports clinical decision

making (Partnership for HITPS 2021).

Voluntary certication for behavioral health

also would be useful for primary care providers,

particularly as Medicaid agencies encourage

integration of primary care, mental health care,

and SUD treatment (NAMD 2021). Primary care

providers should have some of these behavioral

health functions in their EHR because of their own

need to integrate and communicate effectively with

behavioral health providers (Partnership for HITPS

2021). Voluntary certication would help primary

care providers know how to upgrade their systems

to support integrated care models.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

BOX 4-2. Oce of the National Coordinator for Health Information

Technology (ONC) Certication Program, Voluntary Certication for Practice

Settings, and Interoperability Standards Advisory (ISA)

The ONC Certication Program and ONC Interoperability Standards Advisory (ISA) includes health

information technology (IT) standards and functions that support behavioral health care delivery,

including those for capturing and tagging care plans and health data. Having these standards in

an electronic health record (EHR) can provide patients with access to their information and make

them available to transfer between providers during a transition of care.

The ONC Certication Program denes the requirements for health IT and the process by which

health IT may be evaluated, tested, and certied (ONC 2022). Though providers are allowed to use

any EHR they want, the Centers for Medicare & Medicaid Services (CMS) required the use of certied

health IT as part of the EHR incentive payment programs under Health Information Technology for

Economic and Clinical Health Act of 2009 (HITECH, P.L. 111-5). By 2019, more than 90 percent of

hospitals and clinicians eligible for EHR incentive payments used certied technology (ONC 2019b).

The ONC ISA provides the health IT industry with a single public list of standards and

implementation specications that can be used to address healthcare interoperability needs. ISA

also is meant to reect industry discussions about emerging standards and their limitations in

addressing specic functions or interoperability needs (ONC 2019a).

ONC also develops implementation resources and recommends functions and standards for a

voluntary certication for IT used in specic practice settings (ONC 2020e). This approach does

not constitute a separate certication program for the practice setting, meaning that ONC does not

review IT products and assess whether they meet voluntary certication’s requirements. The ONC

approach for doing so consists of three parts:

•

ONC analyzes adopted and proposed certication criteria in the ONC Health IT Certication

Program to ensure these standards are broadly applicable to multiple medical specialties and

sites of service;

•

ONC evaluates standards to determine applicability to medical specialties and sites of service

as well as to the broader care continuum, including the evaluation of such standards for

inclusion in the ISA; and

•

ONC works in collaboration with stakeholders to support the development of resources for

medical specialties and sites of service for which there is an identied need to advance

effective implementation of certied health IT (ONC 2020e).

It is important to note that voluntary certication is not considered a seal of approval or

endorsement from ONC. Rather, it provides a framework to help developers and providers

understand expectations for high-quality tools.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

Encouraging Behavioral

Health Information

Technology

There are a number of ways that federal Medicaid

policies could address barriers to EHR adoption

among behavioral health providers, including

playing a larger role in nancing certied EHR

technology adoption and training and providing

additional guidance on health IT suitability.

Medicaid authorities that can support

behavioral health IT adoption and

interoperability

States currently have the authority to fund EHR

adoption through multiple mechanisms but lack

explicit guidance from CMS on how to do so.

Further guidance from CMS would help states

deploy these authorities to promote EHR adoption

and information sharing among behavioral health

providers and with other providers.

Section 1115 demonstrations. States may

be able to use Section 1115 demonstration

authority to use federal funding for EHR

adoption, but additional guidance is needed from

CMS. For example, in describing Section 1115

demonstration opportunities to improve systems

of care for adults with a serious mental illness

(SMI) and children with a serious emotional

disturbance (SED), CMS explains how states

can use these authorities to support integration

efforts and requires a health IT plan that supports

behavioral health data sharing (CMS 2018,

CMS 2017a, CMS 2017b).

But given that many

behavioral health providers lack an interoperable

EHR and the equipment necessary to exchange

electronic health information, it is unclear how

states can fulll these goals (MACPAC 2021a).

The second area where more clarity is needed

relates to the use of demonstration authority

to provide incentive payments for provider

infrastructure improvements. Under the delivery

system reform incentive payment (DSRIP)

demonstrations, states could encourage provider

investment in technology so long as it supported

clinical and population health improvements

over time (MACPAC 2020, MACPAC 2021b).

Although CMS does not plan to approve new

demonstrations of this type, states are still using

Section 1115 demonstrations for delivery system

reform initiatives. It would be useful for CMS to

clarify the parameters for support of technology

infrastructure improvements for providers who

were previously ineligible for Medicaid EHR

incentive payments under Section 1115 authority

(WAHCA 2021).

Directed payments. CMS guidance on state

directed payments within managed care notes

that EHR incentive payments for providers that

were ineligible for incentives through HITECH is an

allowable use of directed payments (CMS 2016).

In a recent review of directed payment programs,

MACPAC found that only one state was using

directed payments to support EHR adoption as part

of its larger quality strategy for behavioral health

beneciaries (MACPAC 2022). States could benet

from further information from CMS on how states

can use directed payments in Medicaid managed

care for EHR adoption. Refer to Chapter 2: Oversight

of Directed Payments in Managed Care in this report

for more on state directed payments.

Medicaid Information Technology Architecture

(MITA).

MITA 3.0 is the current standard that

states must meet to receive enhanced federal

match for health IT improvements, including

new initiatives to support care integration and

behavioral health IT.

19, 20

CMS guidance notes that

states may obtain an enhanced administrative

match for the development of health technologies

that can be used by Medicaid providers to

coordinate care for beneciaries with serious

mental illness.

However, this MITA guidance,

created by the Substance Abuse and Mental

Health Services Administration (SAMHSA) and

CMS to facilitate coordination, cooperation,

and interoperability among state Medicaid and

behavioral health agencies, is outdated. The

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

behavioral health planning tools and processes

were written in 2008 when most state-run HIEs

were still in development. The tools have not

been updated to reect changes in how Medicaid

supports behavioral health integration efforts or

the CMS and ONC interoperability and information

blocking rules (MACPAC 2021b, CMS 2020, ONC

2020a, CMS 2008). States would benet from clearer

guidance on how the different federal match rates

under MITA could support greater data sharing

among providers.

Federal funding to support technical assistance.

States may need to identify additional sources

of funding to nance technical assistance for

providers, since the use of Medicaid may be

limited to costs associated with the purchasing

of technology. As noted above, other expensive

activities associated with EHR adoption include

education and training, EHR developer selection

and nancial consultations, workow redesign, and

support for connections to an HIE. In recognition

of these additional costs, Congress appropriated

funds under HITECH for regional extension centers

(REC) to support Medicaid and Medicare providers

participating in the EHR incentive programs with

technical assistance around workow redesign

and EHR developer selection. The REC program

was administered by ONC. Providers that received

support from RECs were more likely to meet

and exceed the programs’ quality benchmarks.

However, Medicaid funding for these centers ended

when HITECH sunset at the end of scal year 2021.

Stakeholders have noted the importance of the

SAMHSA-administered Certied Community

Behavioral Health Clinic (CCBHC) expansion

grants in convening working groups that shared

information on EHR developers and workow

design (Hammond et al. 2021, SAMHSA 2022).

Guidance from CMS, ONC, and SAMHSA would be

useful to states trying to blend sources of funding

for technical assistance with those permissible

under Medicaid.

Center for Medicare and Medicaid Innovation

(CMMI) models.

The Substance Use-Disorder

Prevention that Promotes Opioid Recovery

and Treatment for Patients and Communities

Act (SUPPORT Act, P.L. 115-271) authorized

CMMI to test incentive payments for behavioral

health providers who accept Medicaid for the

adoption and use of certied EHR technology.

However, CMMI has no public plans to test such

a demonstration. Although there is interest from

states in exploring this opportunity, states are

unclear on how to apply to use CMMI’s authority

in this way (NASMHPD 2018). States could benet

from information from CMS on how to apply to test

EHR incentive payments under CMMI authority.

Providers need guidance on behavioral

health IT products

In interviews with provider groups and IT experts,

we heard that the purchase of a behavioral health

EHR, particularly one that offers integrated physical

and behavioral health functions, may be dicult

and risky for providers, given that there are no

industry guidelines (Partnership for HITPS). A

voluntary certication outlining IT standards that

support behavioral health clinical functions and care

settings would help providers distinguish among

products to nd one that meets their needs.

To help identify what stakeholders consider critical

behavioral health clinical priorities, the associated

health IT functions, and how they may align with

existing standards and capabilities found in

certied health IT products, we reviewed public

comments on SAMHSA’s proposed rule on Part 2

(SAMHSA 2020), CMS’ interoperability rule (CMS

2020), and ONC’s information blocking rule (ONC

2020a). Below are the ndings.

Guidance on IT standards relevant for specic

practice settings.

One challenge for behavioral

health providers is they are often unclear about

which health IT products meet the needs of

their practice. Other practice settings have had

similar challenges. Under the 21st Century Cures

Act (Cures Act, P.L. 114-255), ONC was required

to recommend a series of standards and EHR

functions relevant for pediatric health IT because

of concerns that EHR usability jeopardized the

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

safety of pediatric patients (Pew 2019). Like

behavioral health, pediatric health has specic

privacy needs (e.g., disclosure of sexual history)

as well as specic clinical functions (e.g., weight-

based dosage).

Through a collaborative working group process

with EHR developers and pediatricians, ONC

developed criteria for voluntary certication of

health IT for pediatric care without having to

create an entirely separate certication program

for pediatric care and practice settings.

ONC also

identied relevant certication program criteria and

interoperability standards that supported pediatric

practices. In addition, ONC developed information

resources to support the implementation of health

IT products that meet the voluntary certication’s

recommended criteria (ONC 2020a). A similar

process could be used to develop guidance for

IT used in behavioral health and integrated care

practice settings.

Guidance on data segmentation standards.

Another signicant challenge faced by behavioral

health providers when using health IT is keeping

SUD information private while sharing the rest

of the patient record. Many EHR systems cannot

easily identify which portions of the record contain

Part 2 information, and instead identify patients as

receiving SUD services, which restricts access to

functionally all of that patient’s data (ECRI 2019,

Hammond et al. 2021, MACPAC 2018, Partnership

to Amend 42 CFR Part 2 2021).

The experience

with pediatric health IT shows that segmentation

is feasible. That is, separation of a child’s sexual

history for pediatric health IT requires a similar

permissions structure as the separation of SUD

treatment information (ONC 2020d).

ONC and SAMHSA co-developed open-source

SUD consent management tools in 2016, however,

implementing these segmentation tools can be

burdensome, and these open source segmentation

tools may need further renement before they

can be used easily among providers who are not

familiar with Part 2 privacy requirements (SAMHSA

2020, Netsmart 2019). Creation of a voluntary

certication for behavioral health practice settings

would help providers and developers understand

which IT standards support compliance with Part

2 and which can be readily implemented within

behavioral health and integrated care settings.

Moving the eld

The Commission considers requiring the use of

IT products with Part 2 segmentation capabilities

among behavioral health providers to be a long-

term goal. However, this goal is not practical in the

near term. It would require widespread adoption of

EHRs that work for behavioral health providers, and

widespread availability of IT tools that support Part

2’s SUD privacy protections.

CMS has the discretion to add health IT

requirements to its conditions of participation for

Medicare and Medicaid participating providers.

For example, CMS requires most hospitals to be

able to send and receive electronic patient event

notications, which generally requires the use of

certied EHR technology (CMS 2020). Similarly,

additional data privacy or clinical function that

supports beneciaries with behavioral health needs

could be added as condition for participation.

When these IT systems are more mature, CMS

could consider requiring the use of health IT that

meets the voluntary certication benchmark for

behavioral health. However, the Commission

understands this is not feasible in the near future.

Commission

Recommendations

In this report, the Commission recommends that

the Secretary of HHS provide states with guidance

on how to use Medicaid authority to promote

EHR adoption, and that HHS develops a voluntary

certication for health IT essential for the delivery

of high-quality behavioral health care that also

complies with state and federal privacy and

security laws.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

Recommendation 4.1

The Secretary of the U.S. Department of Health

and Human Services should direct the Centers

for Medicare & Medicaid Services, the Substance

Abuse and Mental Health Services Administration,

and the Oce of the National Coordinator for

Health IT to develop joint guidance on how states

can use Medicaid authorities and other federal

resources to promote behavioral health IT adoption

and interoperability.

Rationale

A variety of Medicaid authorities could be used

to support EHR adoption and interoperability;

however, states do not have a playbook for how to

deploy these resources appropriately (DHCF 2021,

DHS 2021, CMS 2018). More explicit instructions to

states on how to use different Medicaid authorities

to support behavioral health IT would help states

advance behavioral health integration efforts.

Our ndings suggest that there are multiple

mechanisms that can be included in a playbook

encouraging health IT adoption for behavioral

health. MITA governs the rules for health IT

funding, but has not updated its behavioral health

guidance since 2008 (CMS 2008, MACPAC 2021a).

Directed payments, Section 1115 authority, and

CMMI’s demonstration authority could be used to

promote EHR adoption among behavioral health

providers, but states may be unsure how to deploy

these authorities to improve provider IT. In addition,

other existing sources of federal health IT funding

from SAMHSA, and future ONC funding, may need

to complement Medicaid spending by funding

technical assistance necessary to support EHR

adoption, use, implementation and exchange.

Additional guidance from CMS, SAMHSA, and ONC

could outline how states can combine various

funding streams to encourage behavioral health

providers adopt health IT.

At a minimum, such guidance should:

•

update the MITA rules governing how

states can use an enhanced federal match

to promote integration of services for

beneciaries with behavioral health needs;

•

address how states could use Section 1115

demonstration authority to develop an EHR

incentive program, including potential ways for

states to meet budget neutrality requirements;

•

explain how states can use directed payments

via managed care plans to promote EHR

adoption for behavioral health providers,

including how different types of EHR incentive

payments can be classied under medical loss

ratio calculations;

•

discuss how states could nance the

technical assistance necessary for providers

to incorporate health IT into their workows

and achieve meaningful use of an EHR;

•

address how states can use Medicaid,

including the enhanced administrative federal

match, to pay costs related to HIE services

that support behavioral health data consent

management and interoperable data sharing;

•

address how states can combine Medicaid

with other federal funding streams such as

SAMHSA-administered grant opportunities to

promote behavioral health EHR adoption and

interoperability; and

•

explain how states can use the CMMI

SUPPORT Act authority to test EHR incentive

payments for behavioral health providers

enrolled in Medicaid.

Implications

Federal spending. This recommendation would

not have a direct effect on federal Medicaid and

State Children’s Health Insurance Program (CHIP)

spending. Depending on how states respond

to guidance by encouraging IT adoption or

encouraging greater behavioral health use of HIEs

and other general connections to state IT systems,

costs to the federal government could be affected.

The extent to which spending would increase or

decrease is dicult to predict.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

States. This recommendation would give states the

option to advance clinical integration goals through

greater uptake of behavioral health IT. Providing

guidance to state Medicaid and CHIP ocials on

these different Medicaid authorities would help

remove technological barriers to clinical integration

for patients with behavioral health needs. For these

states, greater behavioral health IT funding would

have other positive implications for other uses as

well. This includes greater state capacity to collect

data needed for the Adult and Child Core Set and to

encourage behavioral health participation in value-

based payment (VBP) programs.

Enrollees. To the degree that additional federal

guidance supports states’ ability to encourage

greater use of behavioral health IT, it could enhance

integration of behavioral health services by

strengthening care coordination and data sharing.

Greater information sharing is correlated with

better patient health outcomes, which includes

lower readmission rates, lower risks of medication

discrepancies, reduced redundant testing, and

decreased emergency department use (Boockvar et

al. 2017, Vest et al. 2015, Yaraghi 2015).

Plans and providers. Providers would benet from

greater funding for EHR adoption and more funding

for broader data sharing integration efforts via

HIEs and coordination with home- and community-

based service providers. Providers would have

improved capabilities to integrate care for patients

with behavioral health needs. Plans would benet

from guidance that encourage EHR adoption via

directed payments because they could receive data

from their behavioral health providers. This data

could help inform integration efforts, support the

development of VBP arrangements for behavioral

health, and support submission of data on quality

to states.

Recommendation 4.2

The Secretary of the U.S. Department of Health

and Human Services should direct the Substance

Abuse and Mental Health Services Administration

and the Oce of the National Coordinator for

Health IT to jointly develop a voluntary certication

for behavioral health IT.

Rationale

Current behavioral health EHR products are of

poor quality primarily because many do not allow

for segmentation of data related to SUD protected

under Part 2 (ABHW 2021, BHIT 2021, WIDHS

2019). Because such information cannot be

disclosed, or redisclosed, without patient consent,

behavioral health providers subject to Part 2 would

benet from systems that include Part 2 consent

management tools and associated permission

structures. Without such systems, behavioral

health providers will be unable to electronically

segment Part 2 records and share the rest of the

patient’s record.

This recommendation calls on ONC and

SAMHSA, in collaboration with providers and EHR

developers, to recommend a set of IT standards,

implementation resources, provider manuals,

and other resources to address behavioral health

clinical and privacy functions.

The Commission discussed a more aggressive

approach of requiring all behavioral health

providers enrolled in Medicaid to use health IT

tools that segment Part 2 protected information

and meet other functions important for behavioral

health and integrated care settings. The

Commission ultimately decided on improving

products and encouraging adoption as a rst step.

Advantages of this approach are that:

•

it would help behavioral health providers know

which EHR platform meets their needs;

•

it would allow for development of robust

consent management tools that support Part

2 compliance, allowing providers to keep SUD

data private, and share the rest of the patient

record; and

•

it would not require the use of Part 2 consent

management tools by other providers until

these are more mature.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

A voluntary certication also would provide a

non-nancial incentive for adoption because

providers practicing in integrated care settings

would know how to upgrade IT systems to support

Part 2 segmentation, but can still send and receive

the patient’s other health data. Furthermore, a

voluntary certication approach could outline a

set of standards that support behavioral health

provider needs, which would further promote EHR

adoption. Recommended standards could support

EHR functions for tele-behavioral health visits,

mental health screening tools, and connecting to

SUD registries or Prescription Drug Monitoring

Programs (PDMPs) (Partnership for HITPS 2021).

ONC should replicate the process used when

it created its recommendations for voluntary

certication for health IT in pediatric care settings,

which were released in 2020. Developed in

collaboration with providers and EHR developers,

ONC recommended a set of standards and

functions aligned with ONC’s interoperability

and certication framework and included

implementation resources for providers and EHR

developers to support the customization of their

EHR platform (ONC 2020b and 2020d).

Given the prevalence of SUD within the Medicaid

population, IT that can support Part 2 compliance

is urgently needed for all Medicaid providers.

However, such tools are still in their infancy and

standards that support them may require further

development and testing before being considered

as a Medicaid requirement. Although a voluntary

certication for IT in behavioral health and

integrated behavioral health practice settings is a

less aggressive approach, it could provide a path to

more stringent requirements when those standards

are more mature.

Implications

Federal spending. This recommendation would not

have a direct effect on federal Medicaid and CHIP

spending, although ONC and SAMHSA would incur

costs associated with undertaking these activities.

States. This recommendation would create a

federal standard to support state efforts. That is,

if a Medicaid agency decides to encourage EHR

adoption for behavioral health practice settings,

it could require providers to adopt an EHR that

complies with the behavioral health voluntary

certication.

Enrollees. In the near term, patients receiving

services from a provider that upgraded their system

to meet voluntary certication would benet from

the potential for greater communication regarding

their care.

Plans and providers. In the near term, providers

would benet by having guidance on a set of

standards and functions that support behavioral

health. Behavioral health providers could work with

a developer on an IT product that meets the needs

of their practice setting. Physical health providers

could use implementation resources to upgrade

their systems to support SUD privacy protection

requirements. Standards outlined under the

voluntary certication could support tele-behavioral

health services, crisis counseling, and connections

to SUD registries and PDMPs. Plans and providers

would be in a better position to provide integrated

care through greater information sharing. In

the long run, as behavioral health IT systems

improve and mature, additional federal action

could be contemplated to make the behavioral

health certication benchmark mandatory. This

action would further facilitate care integration

efforts, especially for providers who serve patients

receiving SUD treatment.

Endnotes

For example, 55 percent of Medicaid beneciaries have

a serious mental illness and a serious physical health

condition compared to 46 percent of privately insured

patients (MACPAC 2021a). In addition, 36 percent of

Medicaid beneciaries have a serious mental illness and

SUD, compared to 27 percent of privately insured patients

(MACPAC 2021a).

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

In order to convey condence that electronic health

information can be easily shared between providers using

different IT systems, ONC certies IT systems to conrm

that they meet a set of minimum quality standards. Non-

certied health IT may store health records in a non-

standardized structure, making it a challenge to transfer

data between providers. Because certied IT systems meet

minimum standards on core functions and data structures,

they are more likely to facilitate interoperability and data

exchange when compared to non-certied IT systems.

The regulation at 42 CFR Part 2 established patient

protections and set the conditions for disclosure and

redisclosure of SUD treatment and prevention records

for people receiving treatment from federally assisted

programs. These regulations rst were promulgated in

1975 and implement statutory requirements intended

to encourage individuals to seek treatment for SUDs

by addressing the stigma of SUDs and concerns that

individuals receiving treatment could be subject to negative

consequences from unauthorized disclosure of their patient

records. The Coronavirus Aid, Relief, and Economic Security

(CARES, P.L. 116-136) Act requires changes to 42 CFR Part

2. Rulemaking on the CARES Act is in progress by SAMHSA

and the U.S. Department of Health and Human Services

Oce of Civil Rights.

Additionally, designing and maintaining systems that

comply with Part 2 requirements (including incorporating

updates such as those made by the 2017 and 2018 Part 2

regulatory changes) can be costly (MACPAC 2018).

Even if a provider adopts certied EHR technology there

are additional costs associated with sharing data with other

providers. These may include technical on-boarding into

an information exchange, fees charged by a state HIE, and

legal counsel for interpreting HIE legal agreements.

Hospitals that were eligible for HITECH’s incentive

payments were primarily pediatric and short-term acute

care hospitals. Psychiatric, long-term acute care, and

rehabilitation facilities were ineligible for incentive

payments.

Most licensed physicians were eligible for HITECH

incentive payments, including psychiatrists and addiction

medicine specialists.

The National Council for Mental Wellbeing’s survey

found that, overall, 67 percent of mental health and

addiction treatment organizations had increased demand

for services. They found this was also true for 63 percent

of youth mental health and addiction treatment services

(NCMW 2021).

In addition to 42 CFR Part 2, other privacy laws such

as Health Insurance Portability and Accountability Act of

1996 (HIPAA, P.L. 104-191) and state behavioral health

privacy laws also create additional costs for providers

regarding consent around the disclosure and redisclosure

of medical records.

Certication of health IT includes privacy and security

provisions, which can help a user to comply with HIPAA. To

further assess compliance with HIPAA, CMS also requires

providers or health care organizations to complete a security

risk analysis by the provider or health care organization.

In this report, we use the term HIPAA as a shorthand for

both the HIPAA statute and its implementing regulations.

There are many reasons why a patient receiving SUD

treatment may not want to disclose their treatment

information. A good example is that there remains

signicant stigma against persons with SUD affecting

housing, employment, and education (NASEM 2016).

This is one reason why some patients do not want their

SUD records shared or want them to be shared with some

providers but not others. When patients are unable or

unwilling to authorize Part 2 programs to disclose SUD

treatment information, inadequate or even dangerous care,

such as prescribing medications with dangerous or deadly

interactions, may be the result (SAMHSA 2018, Wakeman

and Friedman 2017, APA 2016, MHA 2016).

Segmentation capabilities support the sharing of Part

2-protected information within accordance with state

and federal law (ONC 2015). Data segmentation includes

capabilities to tag health care data and allow certain

documents, messages, or individual data elements to be

marked as sensitive, without restricting access to the entire

EHR. This is typically not automated and is not a common

feature within an EHR platform.

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

June 2022

For example, ONC and SAMHSA have developed the

Data Segmentation for Privacy (DS4P) standard and the

Consent2Share software application to manage patient

consent preferences and share Part 2-protected information

electronically through EHRs and HIEs. The Health

Information Technology Standards Committee advising

ONC called into question the maturity of the DS4P standard,

suggesting that additional testing and renements are

needed (MACPAC 2018).

The CARES Act also requires the Secretary of HHS to

update federal regulations to align with statutory changes

to SUD condentiality standards. As of April 2022, HHS is

still in the rulemaking process, and this provision has yet to

be implemented.

The Medicaid EHR Incentive Program is now called

Promoting Interoperability and has gone through

many name changes since its inception. Promoting

Interoperability is now the umbrella term for most of the

EHR incentive payment programs. The Medicaid component

of Promoting Interoperability is administered by the states.

This name change went into effect in April 2018.

This demonstration opportunity requires states to

increase the availability of community-based mental health

care, including non-hospital-based and non-residential

crisis-stabilization services, in order to receive a federal

match for mental health services rendered in institutions for

mental diseases.

States must develop a health IT plan that describes

the state’s ability to leverage health IT, advance HIEs, and

ensure health IT interoperability in support of the program

goals. These health IT plans must address electronic

care plan sharing, care coordination, and integration of

behavioral and physical health (CMS 2018).

States can receive an enhanced federal match for certain

administrative health IT expenses under Section 1903(a)

(3)(A) and (B) of the Social Security Act. This includes a

90 percent federal match for the design, development, and

implementation of mechanized claims processing and

information retrieval systems and a 75 percent match for

maintenance and operations of these systems.

For example, the enhanced federal match could be

used for data-sharing capabilities between hospitals and

community-based mental health providers such that when

a beneciary is discharged from a hospital, their treatment

record could be transferred to a community-based mental

health provider, or if the beneciary was being admitted to a

hospital for acute care, the mental health provider could be

notied easily. Such funding also can be used to promote

data sharing between schools, hospitals, primary care, and

specialized mental health providers (CMS 2018).

SMI and SED guidance states that the enhanced federal

match used to improve state IT systems could be made

available to states to develop data-sharing capabilities

among hospitals and community-based mental health

providers such that when an SMI diagnosed beneciary

is discharged from a hospital, the treatment record could

be transferred to a community-based treatment provider.

Another example is if the beneciary was being admitted

to a hospital for acute care, the community-based mental

health provider could be notied through an automated

electronic messaging service.

Regional Extension Centers (RECs) were organizations

that supported provider EHR adoption during the

implementation of the Medicaid EHR incentive payment

program. The HITECH Act created a grant program through

which ONC provided funding to organizations that provide

on-the-ground technical assistance for individual and small

provider practices that have historically had challenges

effectively integrating health IT into provider workows in

ways that strengthen quality of care (Crabtree et al. 2011,

Lynch et al. 2014). Providers who received support from

RECs were signicantly more likely to meet the milestones

of the Promoting Interoperability program when compared

to providers who did not receive support from RECs (e.g., 68

percent of participants in the REC program achieved Stage

1 meaningful use of EHRs of the incentive program by May

2014, compared to 12 percent of nonparticipants, (AIR

2016)).

SAMHSA’s Substance Abuse and Mental Health Block

Grant allows states to use funds for EHRs but are limited by

statute to ve percent of funds for administrative services.

States that receive funding through SAMHSA’s Community

Mental Health Services Block Grant (MHBG) and Substance

Abuse Prevention and Treatment Block Grant (SABG)

programs can use funds to support administrative activities

including the costs for implementing electronic health

records and other health information technology. However,

Chapter 4: Encouraging Health IT Adoption in Behavioral Health: Recommendations for Action

Report to Congress on Medicaid and CHIP

by statute, states cannot spend more than ve percent of

their grant on administrative expenses (SAMHSA 2022).

As previously discussed, the use of certied health

IT is technically voluntary for providers. However, since

providers were required to use certied EHR technology to

participate in the EHR incentive payment programs for both

Medicare and Medicaid, use of a certied tool became the

industry norm. When the Commission discusses voluntary

certication for IT used for behavioral health, this means

providing a list of standards and EHR functions that

support clinical, security, and privacy needs of behavioral

health providers.

These recommendations were published in June 2020

and included implementation guidance for pediatric

capabilities that developers and providers could use for

pediatric-focused IT. For example, ONC recommended

that pediatric-focused IT should compute weight-based

drug dosages, synchronize immunization histories with

registries, and segment access to sensitive information

such as a child’s sexual history (ONC 2020b). The

recommendations also provided guidance that EHR vendors

could use to design a pediatric-focused IT systems that

also met the requirements of CMS’ interoperability rule and

ONC’s information blocking rule (CMS 2020, ONC 2020a).

ONC’s voluntary certication of health IT for pediatric

settings of care built on top prior federal efforts to improve

pediatric health IT; specically, it was built on top of the

Children’s EHR Format. The Children’s EHR Format tried to

bridge the gap between what was available in most EHRs

at the time and what was needed to provider higher quality

care for children. The Format was authorized by the 2009

Children’s Health Insurance Program Reauthorization Act

(CHIPRA, P.L. 111-3), and was developed by Agency for

Healthcare Research and Quality (AHRQ) in coordination

with CMS (AHRQ 2022).

MACPAC made several recommendations regarding

clarifying key 42 CFR Part 2 provisions; however,

this predates congressional action on SUD privacy

requirements. The Coronavirus Aid, Relief, and Economic

Security Act (CARES Act, P.L. 116-136) aligned the statutory

basis for Part 2 more closely with HIPAA. However, some

issues related to patient consent and electronic information

sharing were not directly addressed by the CARES Act and

will instead be addressed through future rulemaking.

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pmc/articles/PMC7784316/pdf/ocv068.pdf.

Commission Vote on Recommendations

105

Report to Congress on Medicaid and CHIP

Commission Vote on Recommendations

In MACPAC’s authorizing language in Section 1900 of the Social Security Act, Congress requires the

Commission to review Medicaid and CHIP policies and make recommendations related to those policies

to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states in its

reports to Congress, which are due by March 15 and June 15 of each year. Each Commissioner must vote

on each recommendation, and the votes for each recommendation must be published in the reports. The

recommendations included in this report, and the corresponding voting record below, fulll this mandate.

Per the Commission’s policies regarding conicts of interest, the Commission’s conict of interest

committee convened prior to the vote to review and discuss whether any conicts existed relevant to

the recommendations. It determined that, under the particularly, directly, predictably, and signicantly

standard that governs its deliberations, no Commissioner has an interest that presents a potential or

actual conict of interest.

The Commission voted on these recommendations on April 8, 2022.

Encouraging Health Information Technology Adoption in Behavioral Health:

Recommendations for Action

4.1 The Secretary of the U.S. Department of Health and Human Services should direct the Centers for

Medicare & Medicaid Services, the Substance Abuse and Mental Health Services Administration, and

the Oce of the National Coordinator for Health Information Technology to develop joint guidance

on how states can use Medicaid authorities and other federal resources to promote behavioral health

information technology adoption and interoperability.

4.2 The Secretary of the U.S. Department of Health and Human Services should direct the Substance

Abuse and Mental Health Services Administration and the Oce of the National Coordinator for

Health Information Technology to jointly develop a voluntary certication for behavioral health

information technology.

4.1-2 Voting

Results # Commissioner

Yes 15

Allen, Bella, Brooks, Burwell, Carter, Cerise, Davis, Douglas, Duncan,

Gordon, Heaphy, Johnson, Lampkin, Herrera Scott, Weno

Not Present 1

Scanlon