Clinician's Corner

Implementing the Electronic Health Record - An Ongoing Process

By Chester "Chet" Brodnicki
August 1, 2008

Conversion to Electronic Health Records does create challenges for healthcare organizations that results in an ongoing but, ultimately, beneficial process for the organization and, most importantly, the clients it serves. Packaged softwares are available, but are often not flexible enough to meet the particular needs of a nonprofit organization. Also, due to varying internal and external factors, to ensure successful and effective implementation of the EHR there needs to be an ongoing commitment of time and effort by the agency going through the conversion. This article highlights one child mental health facility's experience with its conversion in 2007 and, based on that endeavor, offers factors to consider when contemplating such a conversion.

Clifford Beers Guidance Clinic, Inc., (the Clinic) founded in 1913, is a child psychiatric outpatient clinic that provides a wide range of therapeutic and prevention services including individual, group and family treatments, 24 crisis intervention services, specialized treatment for youth engaged in sexually inappropriate behaviors, treatment for children and youth who have been traumatized as a result of sexual and physical abuse, and parent education programming. The Clinic decided to move to EHR in 2006 following its dissatisfaction with its off-site billing service, its need to have improved clinical record keeping practices and to provide for more consistent and confidential access to and transfer of client healthcare information in an expeditious manner.

With grant support from federal and state agencies as well as corporate and private foundations it was also essential that the software had the capacity to support the Clinic's efforts in its implementation of evidenced based practices. The agency had a 3 year Substance Abuse and Mental Health Services Administration (SAMHSA) grant to implement a Trauma Focused Cognitive Behavioral Therapy evidence based practice and the CT Department of Children and Families was also seeking evidenced based practices in its support of child mental health services.

It was also essential that the Clinic have a better mechanism for clinical case reviews and oversight of clinical decision making and practices. As the number of clinical services provided each year continued to increase the degree of accountability dramatically increased and so the Clinic was also looking for a software package that could help address these clinical needs.

It is important to indicate here that as a nonprofit agency, the Clinic receives significant support from various outside funding bodies. Specifically, grant support comes from the City of New Haven, the CT Department of Children and Families, the federal Substance Abuse and Mental Health Services Administration, the United Way of Greater New Haven, and various private and corporate foundations. Each of these funding sources has dissimilar data and record keeping reporting requirements. The Clinic also serves clients who have commercial insurance or are self pay and a large population of children enrolled in the HUSKY program, administered through an Administrative Service Organization (ASO), which has its own set of clinical, data and billing requirements. Thus, the Clinic was in search of a software package that could meet, to a significant extent, multiple clinical, administrative and financial needs of the Clinic.

The Clinic met with representatives from a few companies that had "packaged" software products that did not meet the depth and scope Clinic's need for software that would not only ensure that quality mental health clinical record keeping was in place, but that demographic and clinical data could be collected, records could be easily monitored for Quality Improvement and billing as well as needed financial reports could be generated in a timely manner. In addition, most companies had packages that were based on medical office practices, not mental health record keeping and billing and were costly. The Clinic then learned of SeginusMD, located nearby in Hamden, CT, which had developed and implemented a software package called SeginusABC for the publicly funded nonprofit agency in the Los Angeles County in Los Angeles, CA . The software that had been developed included both clinical record keeping, quality assurance capacity and billing capabilities. Although the software developed was specifically for an adult mental health system, SeginusMD was interested in working with the Clinic modify the software to meet the needs of a child mental health facility. Thus, SeginusMD was selected as the company with which to contract.

The implementation process began in January, 2007 with a SeginusABC System Specialist and a Training and Support staff person assigned to the Clinic to work on the development and implementation of the software. The Clinic's team consisted of an administrator who was Project Manager, representatives from key clinical programs, the Quality Improvement staff person, a research staff person, a member of the triage team, and a representative from the billing and finance office. The Clinic's technology consultant also participated in the meetings on an as needed basis. A particular challenge for the both groups was developing a means to collect demographic and clinical data and enhance the Clinic's billing capacity, while at the same time ensuring that the clinical records met insurance, federal and state as well as commercial insurance and HUSKY clinical record keeping standards. However, it was also essential that the software developed would not be overwhelming for the clinical and triage staff, as well as the billing staff, to use. As a result of these varying factors, the software development required a significant commitment of time and effort by both the Clinic and SeginusABC staff. This time commitment was greater than either had anticipated but was essential to ensure an effective outcome.

To gain commitment to and support of the staff to this significant initiative the Clinic engaged in a variety of "marketing" techniques. These included raffles, newsletters, "brown bag luncheon" discussions regarding the implications of the transition, utilizing an over-arching theme of Transformation. The butterfly was used as a symbol of this change process and so butterflies appeared in various ways throughout the change process to stimulate excitement about change. All clinical and triage staff were trained in the utilization of the new software.

Prior to going live with the new system in July 2007, the Clinic had to purchase additional computers and hardware so that all clinicians had computers that were networked and that the staff were "computer literate," all interns had access to computers, and all triage staff were acquainted with new triage procedures. The billing component of the software was delayed in implementation for a few months due to the significant time commitment needed in tailoring and implementing the clinical software component.

Since the implementation of the EHR, there has been significant improvement in clinical record keeping with therapy session notes more clearly related to treatment plans. The clinical notes are also legible which is of significant benefit to clinical supervisors. There is greater ease in accessing and retrieving information about individual clients and the services being provided. 90 day clinical reviews are now occurring on a consistent basis on all case records, which had been a major challenge in the past.

There is still work to be done, including billing and financial report preparation. Also, some components of the clinical recording keeping software have had to be set aside as greater attention has been paid to billing and finance related matters. The Clinic and the SeginusABC staff continue to work closely as both parties are committed to seeing that this system is viable in all ways. As stated earlier, the Clinic chose to have a relationship with a vendor to build a system that met the needs of the organization rather than purchasing a software package that didn't.. Thus, the resultant is recognition that the process is iterative and that there continues to be modifications and enhancements as the implementation process proceeds.

As a primary provider of child mental health services in the state, it is critical for the Clinic to be able to continually assess its clinical practices, looking at treatment effectiveness while at the same time looking at developing new therapeutic approaches to address the clinical needs of an urban, low income client population. Through the implementation of the current federally Trauma Focused Cognitive Behavioral Therapy program the clinical staff have identified areas where modifications in its implementation is needed. Thus, having the capacity to track those changes and measure their impact is essential to advance clinical practice. Also with the increased emphasis on oversight by the federal government of Medicaid reimbursement for mental health services it is critical for the Clinic's leadership to be able to closely monitor the clinical and record keeping practices of the staff. Through the ongoing work collaborative with the Seginus ABC software the Clinic can have the capacity to address these needs, thus continuing to be a recognized leader in the provision of quality mental health care for children and families.

In reflecting on these initial phases of the early implementation of introduction of the EHR to this particular agency, things that were learned that, hopefully can be useful for others are:

•  Moving to Electronic Health Record keeping in a clinical setting is a major culture shift and requires significant time and energy in planning, training and adjusting the system as new issues arise.

•  Implementation of EHR is an ongoing process as new data requirements are established by funders and more clinical data is required by Quality Improvement personnel.

•  When different fund sources require differing data sets for specific programs, implementation of an EHR into one standardized data gathering format is not always feasible.

•  Agencies need to take time to conduct a "readiness assessment" in moving to EHR to ensure that the capacity and commitment is there to implement such a major change.

•  Ongoing training of the staff in the use of the program is essential to ensure adherence to the systems/s protocols.

•  Additional staffing may be needed, particularly in the area of QI and data management.

•  Identifying a software vendor that has a software package that is flexible and a staff that is willing to take the time to learn and understand the diverse clinical, statistical and billing needs of the individual agency.

•  An understanding between the agency and the vendor that the installation of a software package is only the beginning of an ongoing working relationship as reporting needs and clinical practices change with the demands of the primary funders.

•  A recognition by the vendor that in the development of software to track the delivery of mental health services the primary user of the software, the clinician, must have a product which is relatively easy to work with and not excessively time consuming.

•  For greatest cost effectiveness the software system should be Internet based, and serious consideration should be given for having the software hosted offsite and that the software is offered as a service.

Chester "Chet" Brodnicki is a former Executive Director of Clifford Beers Guidance Clinic, Inc.