Supporting NCCBH in Washington

Last week I attended the NCCBH Hill day in Washington, D.C. to lobby on Capitol Hill for legislation that supports the mental health community.  We addressed many issues effecting the industry (a list of the agenda we addressed can be found at the National Council for Community Mental Health website), but I particularly focused on one that effects the users of our Electronic Medical Record systems:  The Support the Community Mental Health Services Act (H.R 5176/S. 2182).  

This act addresses the need to provide funding to co-locate primary care/chronic care services at CMHCs; to integrate treatment for co-occuring mental heath and substance abuse disorders; to provide funding for workforce recritment and retention; to enhance behavioral health eduction and training; to provide funding for telepsychiatry and patient education; and finally one that directly impact users of electronic health records, psychiatric software, and medication management systems.  This final measure would require the Secretary of HHS to collaborate with the Office of the national coordinator to develop a plan to ensure that components of the National Health Information Infrastructure address the needs of behavioral and substance abuse providers.  

I met with Senator Hilary Clinton, Senator Charles Schumer and Congressman Steve Israel and got very good response from all offices.  We requested that they co-sponsor the legislation and endorse it.  I recommend that each of you communicate with your local legislators and request the same.  It is easier than you think.   

When/Will Consumer Directed Healthcare Impact Behavioral Health?

At Netsmart Connections we spent time talking about the trend toward consumer centric care and involving the consumer in the care process.  We discusssed consumer portals that provide consumers with access to their electronic health record and medication histories.   

As part of that discussion we looked at how the cost of healthcare is impacting the US economy and several changes to the system that are being proposed to address the problem.  Yesterday I had a conversation with Ryan Daniels from William Blair, Netsmart's investment banker.  I have attached two of Ryan's market analyses (his 2007 and 2008 updates on the CDHC impacts to the healthcare provider markets) in which he looks at how Consumer Directed Healthcare (CDHC) is or will be affecting the primary care marketplace.  Although these reports look at primary care primarily, he does speak about how some behavioral healthcare providers are well positioned going forward because they are less dependent on government funding.  This does not apply directly to many of you, but is a trend worth following as we often see funding approaches that are first tried on the primay care market work thier way into the behavioral health markets.

The question to be discussed is if and/or when this trend will impact behavioral health and public health.  I have had several discussions down in Washington as to how these trends will impact the medicaid and indigent populations and I have gotten several different answers:  1) it wont; 2) they will be treated differently; 3) thier HSAs will be managed by someone for them.   It is not clear where this is going, but it is a trend very much worth watching. 

If anyone has any input please contribute to the group.

External Connected Care

In my last blog entry I discussed Internal connected care.  To truly have connected care, internal connected care is the enabling technology to facilitate external connected care.  External connected care is the ability to share clinical data between disparate providers.  It allows a discharge summary to arrive at another provider before the consumer arrives to give the agency the consumer's diagnosis, active medications, reason for referral, demographic data and much more.  We call this new product CareConnect, and are using the evolving national standard called a Continuity of Care Document (CCD) transfer information between Avatar, MIS and Insight systems.  

Many behavioral health and public health agencies do not have the resources to Develop and maintain interfaces to various RHIOs and other providers.  The Netsmart CareConnect system will allow them to make a single connection to CareConnect and have Netsmart manage the interfaces to other providers and RHIOs.  Connecting care in this fashion will provide better service to the consumer by reducting potential medication errors and by reducing inpatient admissions by emergency rooms by providing the clinicians with the information they need when they need it.

We are continuing to define and extend the CCD to add behavioral and public health extensions.  At Connections a few weeks ago we had some discussions about these extensions.  Some preliminary ideas were to add components of a substance abuse assessment, a risk assessment and a suicide assessment.  What are your thoughts?

I’ve been writing about “the clinician” as if this word represents a homogenous group of people. Of course, this generalization is not correct, especially when it comes to individuals facing the move from a paper chart to an electronic medical record.  So I like to divide my one big generalization into three smaller ones.  I find it useful to think of three groups of people and ask:

·       who they are?

·       what is their attitude to computers?

·       what does their motivation look like?

 

This blog will focus on the third I call “the Excited.”  These clinicians are younger, computer-philes from our modern computer culture.  They are the kids of the organization. (Is my age showing?)  They are newer to their work and not greatly invested in established roles and methods.  They are also newer to the organization, and less identified with the organization’s history and culture.

 

When facing an EMR implementation, the excited group will probably be – well - excited.  A wise implementer will draw their enthusiasm and knowledge into the implementation effort.  Make sure they are represented in planning groups and tapped to be local champions. I enjoyed a mentoring relationship with two of our up-and-coming clinicians who became great boosters of the EMR in their clinical units.

 

But, no surprise, with the energy and computer skills comes impatience. These computer-philes are used to interacting with action packed graphics, to intuitively following their bliss through hyperlinks and to expressing themselves extensively on MySpace.  The content of the EHR is structured and controlled through required fields and software procedures.  They need help to be patient with the restrictions of the software.  They need help to see that the content designers are not dolts and to accept that there are legitimate clinical and compliance reasons behind design decisions.

 

It is the implementer’s job to ensure that these two last statements are correct.

I recently had two useful pieces of information come to me that illustrate my thoughts on achieving user buy-in to an electronic health record.

 

One was a tip on blogging from our blog host. It introduced me to the acronym WIIFM. The tip reminded us that readers search for and look at blogs, asking, “What’s in it for me?”

 

The other information was told to me by a nurse turned techie/implementer in a large system with over 10 institutions. She described the implementations in two of their facilities. In one, the implementation focused on creating reports for the needs of the top managers. In the other, the implementation team created reports designed to meet the needs of the clinical staff. For example, they created a shift change document for nurses and a report showing treatment permissions coming up for renewal. She described that in the first facility, the implementation had a difficult time winning over clinicians. In the second facility, the clinicians had a much more positive attitude and the implementation went much more smoothly.

 

I believe WIIFM is an absolutely legitimate attitude for a CEO, a supervisor, or a clinician using an EMR. After all we’re talking about the relationship of a user to an electronic health record system It may be long-term but it is not an intimate relationship.  WIIFM is OK. So, implementers, ignore it at your peril!

 

I’d love to hear more stories about where WIIFM fits into your implementation.

Intenal Connected Care

When I think of Connected Care I think of it in three parts:  Internal Connected Care, External Connected Care and Consumer Connected Care.  Today I want to discuss Internal Connected Care.  When I talk about internal connected care I am talking about connecting what were previously independent silos of information in a healthcare organization.   For example, If you can integrate your schedulers, with your front desk, with your clinical staff and finally with your billing department you will make your organization more efficient.  If your system can connect the clinical process with the financial (i.e. require the correct progress note before a service is billed) you will reduce internal overhead.  We have heard repeated stories from clients who have increased their revenues significantly after implementation of an EHR because they were now cpaturing services, and billing for them, that had fallen through the cracks previously.

Yet internal connected care does not stop there.  As we strive to improve the efficacy and outcomes of the treatment provided, implementing electronic medication mamangement systems like e-prescribing and computerized physician order entry (CPOE) allows the clinician to check for adverse drug interactions and to reduce clinical errors caused by transcription or handwriting errors between the physician and the pharmacist. When you add document scanning and management to the mix, you allow the clinical staff to have the best quality information when they need it. 

Internal connected care is designed to increase communication internally to an organization, to remove friction from the process and to allow for the provisioin of the highest level of clinical care possible in the most efficient manner.

I would like to hear your views of internal connected care and how you have implemented systems that help provide higher quality care.

Computer Fluency of Users

Do designated users of the e-Prescribing application have basic computer knowledge? Experience has shown that users familiar with using a computer, whether at home or at work, tend to learn the application at a faster rate than those who do not. To accommodate staff members that are not computer-savvy, your e-Prescribing application should have an intuitive, user-friendly interface, and should offer as much consumer-specific data as is possible to the prescribing physician.

 

Nursing Staff

How many nursing staff will be using the system? What is their receptivity to adopting electronic prescribing? Nurses should be made aware that organizational efficiency may not immediately rise at the point of transition, but over time, e-Prescribing can greatly assist them in a variety of areas, including reducing the number of call-backs from pharmacies, eliminating the need to transcribe medication orders, and improving risk management efforts.

 

Hardware Setup

Does your organization have adequate computer and printing resources for the project to be successful? There should be a computer available for each prescriber to use during appointments. Computer monitors should be positioned so that it is not necessary for the prescriber to turn his/her back on the consumer to issue a prescription. Also, a printer must be stationed nearby to instantly produce prescriptions or collateral information. Experience tells us that the first thing users will complain about during the introduction of new applications is the hardware (e.g., “The printer doesn’t have ink in it so I can’t use the new program”).

 

IT Support

Do your information technology leaders and staff endorse the project? Are your IT specialists working on other projects concurrently? The effort required to implement new systems should not be underestimated, especially in a setting that will bring technology to the desktops of all clinic staff. Assignment of adequate internal IT resources is mandatory to assure project success. 

 

Current Consumers on Medications

How many of your active consumers are on medications? A typical estimate is 60-70% of active charts. Your organization will need to determine the most efficient way to input consumers’ current paper-based medication information into the new system. Many organizations use data entry to do this; but keep in mind that it takes an average of three minutes to enter each consumer’s current medication information.

 

Pharmacy Communication

Have you let all routinely-used community pharmacies know your organization will begin e-Prescribing?  Notifying pharmacies in advance will reduce the number of phone calls that may originate from inquiries regarding the new prescription formats (e.g., confirming authenticity).

 

In Conclusion

More and more behavioral health providers are adopting e-Prescribing as technological advancements and government regulations drive the healthcare industry towards wholly automated processes. Early experience indicates that the benefits of e-Prescribing are real, and by far outweigh the risks and costs of implementation. Transitioning to an electronic prescribing system requires a dedicated investment of your organization’s time, money and resources. Good planning and proactive communication with all internal and external stakeholders will help assure a successful implementation, which, in turn, will result in higher quality care for your consumers.

At a workshop a couple of years ago, a behavioral health executive contemplating an EHR implementation asked me, “How can I get my clinicians excited about this implementation?” My short answers are “Be realistic” and “It depends.”

Clinicians have different needs for information and a different relationship to an EHR than executives. Managers need information to lead the organization. I would also add that they do very little of the direct data input, so they get the benefit of the reports without much personal effort.  Not so for the clinicians who, along with support staff, are the main sources of the content being entered into the EHR. So what might get a busy clinician excited about an EMR implementation? Let’s think about this question from the point of view of salaried clinicians in a behavioral health organization.

Such clinicians are not much interested in organization finances, compliance and other executive concerns.  They too want information, but of a very different sort. They want an efficient method to capture relevant client history.  They would appreciate tools that could help them define the treatment and track progress. They need to communicate with themselves and with other staff treating the client both currently and in the future. Approaching these needs will be experienced as helping them do their core job, providing the best care they can for their patients. So far, so good.  Clinicians further need to capture data and document their work to satisfy all the various data masters of the universe, eg payers and accrediting entities. This is experienced as extraneous to their core job. (They feel grumpy about doing it and will feel grumpy about the EHR that ensures they do it.)  And, of course, they want EHR content to be easy to access and navigate.

If you are an implementer, don’t set yourself up for disappointment by expecting clinicians to be excited about the EHR implementation itself. Moving from paper to computer involves lots of changes for clinicians. A well-executed implementation is critical in getting the EHR off on the right foot. Do understand, though, that the long-term success of the EHR you are implementing depends on how well the system you deploy serves the work the clinicians are doing.  It depends on their having ready access to a computer, on the functionality of the software you have chosen, the design of the content, the usefulness of the outputs, the adequacy of the supports.  None of this is magic. Digging down into the details and finding good solutions at the level of the clinicians at their jobs is the work of the implementation.

I’ll write about my experiences and thoughts on these challenges in future blogs.

Is Your Organization Ready for e-Prescribing? Part I

 

The past several years have witnessed an explosion in the automation of healthcare practices and medicine. And while the adoption of electronic prescribing will undoubtedly yield a variety of benefits to physicians, consumers and payers, there are several organizational factors you must consider before implementing a system of this nature.

 

For e-Prescribing to provide significant value, your staff must utilize the system and, in turn, the e-Prescribing system must deliver the functions desired and required by your organization. The purpose of this article is to provide a framework for the knowledgeable consideration and implementation of an electronic prescribing system. Over the next two blogs I will present a few important elements to think about when faced with the question, ‘What factors do I need to consider ensuring a successful implementation of an electronic prescribing application?”

 

Current Practice Management System

What practice management system is your organization currently using? Does the system have the ability to export a variety of consumer information to the eprescribing system, thus eliminating duplicate entry? If your staff needs to do duplicate consumer demographic entry into an e-Prescribing application, it could hinder adoption and efficiency of the system.

 

Prescriber Adoption and Training

How many prescribers will be using the system? What is their attitude about adopting e-Prescribing technology? Will their schedules allow for necessary training? If a large number of prescribers will use the system, training will likely need to be grouped. Doctors must schedule time to attend the training without overburdening their schedules, and adequate training facilities will be required to accommodate Web-based training for large groups of people.

 

Leadership in the Organization

Is there a clear message from the top leadership of the organization supporting the adoption of electronic prescribing? There must be a strong statement of support for the project from the executive management team, from both organizational and technology perspectives. If your leaders give the impression that e-Prescribing is optional, adoption will be spotty at best.  

Stay tuned for Part II...

          The case for implementing an EHR depends on your point of view.  In this blog, I want us to consider the question from a CEO’s perspective. CEOs spend much of their time monitoring enterprise performance and preparing for and making decisions. This is as true for executives in health care as for those in automobiles and banking. Volumes have been written about these high level tasks and, for sure, I don’t have new insights to add to that body of knowledge. What I want to highlight is the crucial contribution information makes to CEO oversight and decision-making. Courtesy of Wikipedia, I define Information to be "the result of processing, manipulating and organizing data in a way that adds to the knowledge of the receiver." In the domain of health care, information must include data captured through an electronic health record (EHR).  Here’s how this played out at my home organization, University Behavioral HealthCare (UBHC). 

In the mid 1990’s UBHC faced the surging managed care environment with its demands for effective care at lower prices, its requirements for accountability for documentation and outcomes and its focus on customer satisfaction. Our CEO recognized that in order to succeed in this environment the organization needed to use information to:       

• Establish and monitor care and productivity standards
• Optimize and monitor billing 
•  Identify service supply and demand trends  
•  Measure treatment efficacy and patient satisfaction

He further recognized that to accomplish these tasks, he needed the data to be comprehensive, detailed, high quality, and current. Relevant data from all functions of the enterprise had to be captured electronically for executive management control and reporting purposes. For our CEO this case for implementing an Electronic Health Record System was compelling. 

          By July 2000, an enterprise-wide EHR has been implemented. All staff - 500 clinical and 400 support - worked primarily in the EHR. By 2003, more than 1,000 managerial, fiscal, control, QI and clinical reports were in use. Outsourced billing and transcription costs were eliminated, saving $1.4 m per year. Successful billing was increased 10% through monitoring the billing process for problems which would have previously resulted in denials such as a missing Diagnosis or Progress Note. Gross revenues per clinician FTE increased 50% due to the ability to schedule more efficiently, to track work being done and to assist documentation compliance with reminders and to do lists.
          His commitment to the EHR implementation paid off almost immediately. In a recent conversation with him, he told me that he could not imagine trying to lead and manage the organization without the benefits of the EHR.

During this electrifying political season, there is a flurry of attention being given to Electronic Health Records. Nationwide implementation of  EHR’s is a core component of candidate plans to reform the American health care system. The main reasons put forth include to save money, reduce medical errors, avoid redundant testing, identify previously ineffective treatment,  and provide access to current medications from any point of care.   The media is high profiling phrases such as “interoperability,” “RHIO’s” and “Personal Health Record (PHR).”

 

Adding to the intensity of the EHR discussion, the federal government is proposing penalties for EMR non-adopters. Our largest technology companies, namely Microsoft and Google, are charging into competition to capture the hot property of the PHR.

 

Some of the enabling technology for these high level goals is in place. Some crucial components are not. What are the providers of healthcare to do? More particularly, how can those contemplating software for behavioral health, addictions, MRDD and public health approach the question of why should they embark on such an undertaking? Here is my thought. To borrow a saying:

 

Plan globally and for the future………Act locally and for the present

 

An organization’s top planners must be aware of the national vision and policy trends concerning EHRs. They must be informed about technology trends. Only then can they define their own plans and make decisions. For example, they should not cast their lot with a vendor which cannot demonstrate its ability to lead or at least keep up with technical developments over the long haul.

 

But long term visions seldom motivate people to undertake the demanding sort of change involved in an EMR implementation. To achieve buy-in, leadership needs to define goals that address immediate challenges facing the organization. This requires thinking clearly about the organization’s environment, mission and resources. I’ll write about defining these goals in upcoming blogs.

The Vision of Connected Care

Connecting care between departments in an agency, between agencies and between different types of care givers (behavioral health, public health, primary care, social services etc) is designed to improve the quality of care provided to consumers, to reduce the quantity of medical errors (and the costs associated with them) and to improve national defense by more rapidly identifying disease outbreaks.

In addition, Connected Care is designed to achieve another major goal:  bringing the consumer into the care process using consumer portals to provide access to their electronic health records and eventually connecting them to personal health records. 

The genesis of Connected Care at the national level started in 2004 when President Bush outlined his vision of every American having an electronic health record within 10 years and has accelerated as agencies begin to envision the benefits to their clients (listen to what providers are saying).  The figure below provides a real world scenario of how a consumer could use Connected Care:

As consumers move between community mental health centers, county behavioral health agencies, state inpatient psychiatric hospitals, and local public health departments, the goal is to seamlessly transfer clinical data between electronic health records.  Initially this information would contain diagnosis, active medications and reason for referral.  If we can accomplish this, we can dramatically reduce medication errors which cost the country nearly $100 Billion annually.  In future blogs we can discuss each of these areas in more detail.  If you would like to see more information right now visit some of our pre-recorded webinars.

The person leading an Electronic Medical Record (EMR) implementation must know both the clinical and IT terrains. Since these two sets of knowledge don't ordinarily come in the same individual, who is best prepared to lead the EMR implementation effort, a clinician or a techie? I vote firmly for a clinician. Here's why.

 

At its heart, an EMR implementation should be a clinical and business processes undertaking, not an IT project. While an EMR crucially depends on technology, the ultimate purpose is to advance the quality and efficiency of care provided by people for people. The essential  knowledge underpinning an EMR is an intuitive grasp of the flow of the clinical enterprise: how to think, what to ask, how to decide, how to plan, execute and document. Next in line of importance is understanding the requirements of the complex business environment of health care. Then comes technical knowledge: how to exploit the rich computer systems toolkit to capture and enhance the flow and requirements.

 

This is NOT to say that technical knowledge is unimportant. It is essential for an EHR implementer to grasp the core concepts of networks, client-server, databases and reporting. When I began my transition from practicing psychiatrist to EMR implementer, I identified my computer naïveté to be a serious deficiency. So I promptly  enrolled in the introductory computer science course at a local college. I learned about hardware, networks, operating systems, reporting… I even became competent at very basic programming. On my own, I studied databases and taught myself MS ACCESS. I participated in many IT meetings. With focused effort, I learned enough to be an effective member of our IT team. To my surprise I found that computers are great fun – and very useful.  

I have talked with many people embarking on an EHR implementation. I routinely ask, “ Is it easier to teach a clinician the technical side or a techie the clinical side?” The answer is always, “It’s easier to teach the clinician.” What's your vote?