The Oklahoma Health Care Authority’s board is set to vote Wednesday on rules permanently implementing last year’s SB 1369, which would require health care providers across Oklahoma to connect to a new statewide health information exchange. While all providers would be required to join, an annual exemption application could allow some individuals or practice groups not to participate.
The HIE would allow a patient’s doctors and mental health providers to access electronic medical records and share HIPPA-governed health information digitally. HIEs are aimed at streamlining and improving care for those who see multiple providers by allowing those providers to communicate and share data about a patient. For example, an oncologist and a general practitioner could access relevant records and discuss treatment plans for a patient through the exchange.
Every state other than Illinois and New Hampshire has some form of an exchange, and Oklahoma’s existing HIE — the nonprofit MyHealth Access Network — began sharing data among major hospitals and provider groups in 2011. The Cherokee Nation and the Muscogee Nation were founding members of the MyHealth exchange.
Most exchanges are privately owned and operated like Oklahoma’s. (Only Arkansas and Alabama have state-owned HIEs.) Most states have some sort of mandate for participation, generally for specific patient populations and insurance designations.
But with HB 1369 requiring all Oklahoma health care providers to connect to the exchange by July 1, Oklahoma is poised to join Nebraska and North Carolina as one of the few states with a broad provider participation mandate.
As the deadline approaches, the OHCA’s proposed rules governing the exchange recently completed a public comment period that drew criticism and concern from some mental health providers. The questions centered around patient privacy, participation costs and the workload required to upload patient data into the exchange.
Some concerned therapists marched from OHCA to the Oklahoma State Capitol on Saturday in protest against the implementation of HB 1369. Days later, a pair of state agency leaders and two legislators held a press conference this morning to clarify the HIE’s rules for mental health providers and push back against recent rhetoric, which has included some counselors saying they will turn in their licenses and stop seeing patients in Oklahoma if they are required to join the exchange.
“Yes, we could have done a better job communicating this, but I’m astounded by some of the unprofessional conduct of some of our counseling association and some of our counselors,” said Rep. Marcus McEntire (R-Duncan) who co-authored the legislation creating Oklahoma’s statewide HIE. “They’ve chosen to react emotionally and unethically toward the HIE by telling their clients that it is something nefarious and that their sensitive data is somehow compromised or at risk.”
McEntire, Sen. Paul Rosino (R-OKC), OHCA CEO Kevin Corbett and Oklahoma Department of Mental Health and Substance Abuse Services Commissioner Carrie Slatton-Hodges said state and federal laws already impose stringent limitations on how behavioral health care records can be accessed. They said mental health treatment notes have never been proposed for HIE inclusion, unless a patient specifically requests such.
“The law is and has been clear on this data, and I am concerned that those who worked to destigmatize mental health for the last 10 to 20 years have been thwarted — those efforts have been thwarted by this, and it has been done by those administering the care,” McEntire said. “I’m kind of angry about it, but that’s OK. I get that sometimes communication wires get crossed and sometimes people act emotionally and they call in the fire truck before there is really even a fire.”
Pressed to describe how a new patient seeking mental health services would be presented with the HIE, Corbett said mental health providers would be required to ask their patients if they want record of that type of care noted in the system. Corbett said non-mental health providers — like primary care physicians and physician specialists — would simply have their patients sign an acknowledgment that visits and treatments will be recorded in the HIE.
Essentially, that means patients could opt out of having their primary care records chronicled but would have to opt into having their mental health records included.
Slatton-Hodges, the state’s mental health commissioner, said her agency already works to have information integration for patients who encounter crisis centers, recovery centers and other mental health facilities.
“It is so incredibly important when people opt into having their information supplied across the health information exchange because then what happens is when you are not in as wonderful a state as you were the day when you were able to give that approval to share information, and I see you in a crisis situation or when you are not at your best, I am able to see what medications you have been taking, when you had an injection so I don’t repeat that and cause damage to you, so that I know what allergies you have so that I won’t administer medication to you that could cause an adverse reaction,” she said.
‘It should be up to the individual’
Whether the remarks and explanations provided Tuesday by state leaders will calm the fears of some mental health professionals remains to be seen. As word of the HIE rules spread among counselors this month, questions arose about the details of how a patient could choose to have their mental health records exempted from the system.
OHCA officials said the plan was always for mental health records to be able to be kept private, but public comment period feedback resulted in a change in what affirmation is asked of patients.
The existing MyHealth Access Network, which currently acts as an HIE for certain hospital systems, has been selected to manage the new statewide HIE. McEntire noted that the decision means the state will not be managing the personal health information gathered.
Currently, patients in the MyHealth system who have not wanted their information shared have had their records marked “sensitive” in the exchange. Following concern from the mental health community, OHCA asked MyHealth to adjust the process for statewide implementation so that patients must proactively designate their mental health records for inclusion, thus eliminating fear that a document requesting mental health exemption would exist and still reveal who a patient is seeing for mental health care.
Norman-based social worker Lori Roper operates a one-woman practice and has been watching the conversation about Oklahoma’s new HIE. In addition to treating patients, she also serves as her office’s record keeper and receptionist. Roper expressed concern about the privacy of her clients and the heavy workload the HIE would create when it comes to uploading records to the exchange.
Providers must pay about $5,000 to get started on the exchange, and there are other fees beyond that initial expense, although providers can seek exemptions. For an individual licensed professional counselor, the annual fees could total a couple of hundred dollars, according to MyHealth CEO Dr. David Kendrick.
“It will also be very expensive to get started and there are ongoing expenses as well,” Roper said. “Satisfying this mandate, if you are a private practice as a solo provider, would also be extremely time-consuming. I spend about 15 or 20 minutes per patient, per week on clerical tasks, including dealing with insurance companies. And every insurance company has its own way of doing things, so learning all of that is time-consuming. I think most people who are their own receptionist and bookkeeper don’t have time for it.”
Roper said the concept of an HIE makes sense and could have a positive impact on a patient’s care with proper implementation. But she said the proposed rules have also come with problems.
“If you’re a person with multiple conditions and seeing multiple doctors you need a common place for those doctors to communicate,” she said. “But it should be up to the individual not done by the state. There’s also another school of thought that says it’s a high price to pay for that convenience.”
Roper also has concerns about the long-term implications. She said records uploaded to the HIE will likely be permanent, even if a patient is no longer seeking treatment for mental health problems.
“Mental illness isn’t a contagion or pathogen,” she said. “Most mental illnesses are transient. You get the tools, and you work through problems, and you move on. But that stays on your record. I think people want to have autonomy over this. Another issue is people being misdiagnosed. And sometimes it takes a while to get the right diagnosis. Very often a diagnosis can change. I think people want their right to privacy protected.”
Licensed professional counselor Rachel Graham shares Roper’s concerns. She told OKC’s Fox 25 that the HIE will create more privacy concerns for patients and providers.
“When we become therapists, we take an oath to protect people’s privacy,” she told the TV station last week. “If this does go through like they’re saying it’s going to, there won’t be a way for us to ensure that people’s records are private.”
Rosino, the chairman of the Senate Health and Human Services Committee, bristled at that type of remark during Tuesday’s press conference.
“These emergency rules have been out since September. Since September. So there was public comment period, and then within the last two weeks we have been inundated with emails and people stoking a fire that really didn’t need to be stoked,” Rosino said. “And it’s disappointing that the people who care about people and supposedly care about their mental health are the ones scaring them. They are scaring their own patients, and to me that is shameful. It needs to stop, and they need to understand what we’re doing before they put out misinformation.”
But the complicated nature of reading agency rules — the OHCA’s proposed revisions begin on Page 185 of Wednesday’s agenda — and limited communication from the agency exacerbated questions about what exactly the HIE process will look like for mental health care.
Still, not all providers will ultimately have to participate. OHCA deputy director Christina Foss said some exemptions would be granted based on how many people work in a practice and how many patients they see.
“We are continuing to work on the criteria specifics,” she said. “We’ve also heard from a number of providers whose comments have helped guide us through the process.”
Foss said more than 70 percent of Oklahomans have health records scattered across multiple platforms, which makes it harder for a patient’s providers to communicate.
“The goal is to have a place where providers can access this information and use it to improve communication,” Foss said. “Providers directly involved in a patient’s care are the only people who will have access to the information.”
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Lawmakers could appropriate funds to cover one-time setup fee
Kendrick, the CEO of MyHealth (which will serve as Oklahoma’s HIE), said the one-time implementation cost for adding all new providers by July 1 is estimated to be about $30 million. An enhanced stream of federal funding for HIE setup ended in September 2021, but Oklahoma can still leverage additional federal matching funds for Medicaid patients.
Kendrick said MyHealth’s operating budget is about $5 million per year currently, with an estimated budget after the mandate takes effect July 1 running between $12 million and $20 million. Perhaps as much as $6 million of that funding could come from the federal government.
“The upfront cost of connectivity (…) you happen to have a fair amount of surplus at this moment that could be used to offset that burden for providers involved,” Kendrick said.
Kendrick estimated the upfront cost of connecting all provider groups and individual providers will be about $30 million.
Senate Appropriations and Budget Chairman Roger Thompson (R-Okemah) said he wants to see the math behind that number.
“I think $30 million is too high. First of all, we don’t have anything but just somebody pulling a number out — that I’m aware of — that says $30 million. It started out around $25 million, and all of a sudden it went up $5 million over this last week,” Thompson said. “I’m interested in helping, there’s no doubt about it. We need to take a look at it. I don’t know what the end result’s going to be of that, but I want true numbers so that I can go back to the taxpayers and say, ‘This is the actual cost.'”
Thompson said he has asked Rosino to dig more deeply into that potential cost as the Legislature crafts its Fiscal Year 2024 budget for health services.
Lawmakers are also discussing what additional funding may be needed to support OU Health, the state’s unique health care system that has made a variety of operational changes in recent months in an effort to improve revenues and liquidity while it carries a massive debt load.
(Update: This article was updated at 3:43 p.m. Tuesday, March 21, to include additional information about the costs associated with Oklahoma’s new health information exchange mandate. It was also updated to correct references to other states’ health information exchange systems.)
