Implementing Electronic Behavioral Health Record

Implementing Electronic Behavioral Health Record
What It Is & Why Do It Case Studies Implementation Recommendations

Overview What is EBHR & Why Do It A Brief Case Study
Krystyna Riley & Steve Enge A Brief Case Study Steve Enge Process Analysis and Design in Implementing EBHR: Most Important and Most Overlooked Factor Heather McGee, Et. Al. Implementation Recommendations Presentation Format Some slides fully described Some slides summarized Some slides (e.g., References) skipped Some slides have only selected items highlighted So, follow along in your handout See resource references at the end of handout

Central Themes of This Symposium
Information Technology Business Processes Behavior Management Product Selection Vendor Relationship Successful Implementation

What is EBHR, and Why Do It?
Krystyna Riley, M.A. Western Michigan University Steve Enge, IT Systems Architect Kalamazoo Community Mental Health And Substance Abuse Services

What Is EHR? CORE EHR Functionalities
Quick Access to Health Information Support for Service Delivery Processes Support for Financial & Administrative Processes Integration and Coordination of Care Electronic Communication and Connectivity Decision Support Reporting

Regulatory Requirements
Agencies Laws / Mandates Details Funding for Services CMS Centers for Medicare & Medicaid Services HIPAA (1996) Health Insurance Portability & Accountability Act Access, Portability, and Renewability Information Privacy & Data Security Electronic Data Interchange (EDI) Standards Enforcement Medicare Administration Medicare Administration (w/ States) SCHIP Administration (w/ States) LTC Quality Standards Enforcement Lab Quality Standards Enforcement Electronic Health Record (EHR) Health Information Sharing Personalized Care Personal Health Record (PHR) Tele-Health Improve Population Health Evidence Based Practice (EBP) Regulatory Requirements SAMHSA Substance Abuse and Mental Health Services Administration Improve quality & availability of MH & SA Services Reduce illness, death, disability & social cost NOMS National Outcome Measures (MH) TEDS Treatment Episode Data Set (SA) Evidence Based Practice (EBP) Grants Information Technology (IT) Requirements ONCHIT Office of National Coordinator of Health Information Technology Executive Order (2004) Electronic Health Record (EHR) Health Information Sharing (NHIN, RHIO, HIE) Personalized Care Personal Health Record (PHR) Tele-Health Improve Population Health Evidence Based Practice (EBP) ARRA (2009) American Recovery & Reinvestment Act HITECH Health Information Technology for Economic and Clinical Health Act EHR Adoption Incentives Meaningful Use Grants CMS Centers for Medicare & Medicaid Services ONCHIT Office of National Coordinator of Health Information Technology Funding for IT Infrastructure Parity for Behavioral Health Funding CMS – Medicaid CMS – Medicare ONCHIT Extend ARRA, Medicaid, and Medicare funding for HIT to Behavioral Health Providers H.R.5040 Health Info Tech Extension for Behav Health Serv Act of 2010

H.R.5040 Health Info Tech Extension for Behav Health Serv Act of 2010
Introduced: April 15, 2010 Sponsors: Patrick Kennedy D-RI and Tim Murphy (R-PA) Summary: Extends eligibility for funds to behavioral health providers Status: In Committee – Ways & Means, Energy & Commerce What You Need To Do: Contact Your Congress Person Contact Your Senator Watch the Progress Support Lobbying Efforts!!

H.R.5040 Health Info Tech Extension for Behav Health Serv Act of 2010
Make (HIT) funds under ARRA for “meaningful use” of EHR available to certain: Substance abuse professionals and substance abuse treatment facilities Behavioral and mental health professionals and clinics Psychiatric hospitals Extend eligibility for Medicaid HIT implementation funds to certain: Mental health and substance abuse treatment facilities private and public psychiatric hospitals Clinical psychologists and clinical social workers, and other professionals Extend eligibility for Medicare HIT incentives to certain: Physicians, clinical psychologists and clinical social workers Authorize a $15 million ONCHIT grant program for: Facilitating purchase and enhance the use of HIT Training personnel in the use of HIT Improving the secure electronic exchange of health information among providers Improving HIT for adaptation to “community-based behavioral health settings” Assist with the implementation of telemedicine Collaborating and integrating with HIT regional extension centers Stimulus Funds Medicaid Funds Medicare Funds ONCHIT Funds

Michigan Department of Community Health (MDCH)
SAMHSA Requirements MMBPIS – Michigan Mission-Based Performance Indicator System Outcome Measures Employment Status Minimum Wage Status Inpatient Recidivism Recipient Rights Complaints Sentinel Events Suicides Process & Other Measures Service Request  Inpatient Admission Screening Service Request  Outpatient Intake Screening Intake  First Service Inpatient Discharge  Followup Service Requests  Denials  Appeals  Overrides Medicaid Eligible Persons Served Hab Waiver Person Served Administrative Cost / Total Cost Additional Requirements

Nationwide Health Information Network: A Network of Networks
RHIO RHIO RHIO RHIO RHIO RHIO Nationwide Health Information Network (NHIN) RHIO RHIO RHIO RHIO RHIO Governmental Agencies CMS CDC Military VA Etc … Specialized Organizations Public Health Research Quality Assessment Etc …

Regional Health Information Exchange Organization (RHIO)
Labs Pharmacies HIE Regional Health Information Exchange Organization (RHIO) HIE HIE HIE

Health Information Exchange (HIE)
Pharmacies Labs Private HIE Personal Health Record (PHR) PHR Provider Community Health Information Exchange (HIE) Hospitals Other Providers EHR Physician Offices Electronic Health Record (EHR) EHR EHR Care Delivery Organizations (CDO)

What Is EHBR? Components/Functions by Process Step
Registration Eligibility Referral Consent Wait List Screening Assessment Care Plan Authorization Admission Outpatient Services Residential Services Medication Billing Assessment Discharge Plan Discharge Follow Up

Case Study Steve Enge, IT Systems Architect
Kalamazoo Community Mental Health And Substance Abuse Services

Southwest Michigan Urban Rural Consortium
CP CP Barry County SA Allegan County CMH CP CP CP CP CP Kalamazoo Community Mental Health and Substance Abuse Services CP CP Van Buren County SA Branch County SA CP Cass County CMH St Joseph County SA St Joseph County CMH CP CP

Persons Served Fiscal Year 2008: 10,504
Total Budget: $87,857,007

Registration Eligibility Referral Consent Wait List Screening Assessment Care Plan Authorization Admission Outpatient Services Residential Services Medication Billing Assessment Discharge Plan Discharge Follow Up

Tools for Process Analysis and Design
Discussed in some detail in the next presentation For now, let’s look at a Relationship Map

Environmental Factors
Regulatory Requirements Funding Source Requirements Different States, Different Rules HIPAA & EHR Mandates Evidence Based Practice Inadequate IT Infrastructure Cost Reduction Imperative Stimulus Plan Funding Health Care Reform Organization External Providers External Providers Access: Info & Referral Screening HIPAA Compliant EDI Crisis Services Inpatient Admission Dis- charge Discharge Follow Up Services Con- sumers Potential Con- sumers Assess- ment Outpatient Admission Treat- ment Plan Progress Review Consumer Connect (PHR) Eligibility Claims & Billing Progress Notes CPOE Medical Records Provider Connect Small Providers Payors HIPAA Compliant EDI Large Providers MDCH Reporting Financial Operational Process Outcomes

Request for Service (Info & Referral) Request

Request for Service Problem

Request for Service Disposition Drives Workflow

Screening (Eligibility) Clinical Mini-Assessment

Screening Disposition Drives Workflow

Assessment (Needs) Thorough Clinical Assessment

Assessment (Needs) Disposition Drives Workflow

A Cumulative Record View of Implementation
Late Again! Completed EDI Completed Provider Connect Discharge Plan Discharge Follow Up Crisis Plan Information Release Coordination of Care Decision Support And More … Work Started Started Original Due Date Drop Dead Declaration Contract Disputes Attorney Involvement Partial EDI & Provider Connect Authorizations Teaming Challenges Info & Refer Screen Good Teaming Silo Games Inpatient Assess Started Med Review Ideological Conflicts Med Tx Plan Progress Review MH Tx Plan Assessment Progress Notes Appointments Billing 2006 2007 2008 2009 2010 Enrollment Simple Components Financial Imperative

Business Intelligence Project Summary
Levels of Performance Organiza- tional Process Job / Task / Performer Financial Capacity (Learn & Grow) Process Consumer & Stakeholder Perspectives Maximize Revenue Expedite Cash Flow % $ on Admin Costs Cost Per Service Unit Maximum Eligibility Negative Actions Takebacks Claim Acceptance Timeliness, Accuracy, Productivity Eligibility Update ATP Update Service Delivery Progress Note Manager Performance Outcomes Access MMBPIS (PI Report) Recovery SAMHSA NOMs OQ45 Satisfaction MHSIP Evidence Based Practices Goal / Objective Writing Intervention Writing Staff Performance Service Delivery Timeliness Service Delivery Quantity Service Delivery Quality Process Performance Provider Scorecards Organizational Performance Timeliness/Accuracy/Productivity Screening Emergency Responsiveness Intake, IPOS Progress Note, Progress Review Discharge Followup IT Capacity Staff Capacity Employee Competencies Employee Retention Employee Satisfaction Organizational Alignment Job Descriptions Consequences Staff Training Essential Learning Other Training Staff Management Directive Supervision IT Services Solution Provision Operations Support Staff Skill Sets Skill Acquisition Timeliness Accuracy Goal & Objective Completion Maximize Revenue Expedite Cash Flow % $ on Admin Costs Cost Per Service Unit Staff Training Staff Management IT Services Outcomes Access Recovery Satisfaction Maximum Eligibility Negative Actions Takebacks Claim Acceptance IT Capacity Staff Capacity Organizational Alignment Organizational Culture Process Performance Goal Completion Objective Completion Staff Performance Manager Performance Staff Skill Sets Evidence Based Practices Organizational Performance

Heather McGee, Ph.D., James L. Squires, M.S., Krystyna Riley, M.A.
Process Analysis and Design in Implementing EBHR: Most Important and Most Overlooked Factor Heather McGee, Ph.D., James L. Squires, M.S., Krystyna Riley, M.A. Western Michigan University Jean M. Pavlov NorthCare Network Ralph Olson, Ph.D., BCBA, Claudia Johnson Pathways Community Mental Health

NorthCare Network The NorthCare Affiliation – formed February 2002 Pathways Community Mental Health – Lead Agency Copper Country Mental Health Services Gogebic County Community Mental Health Authority Hiawatha Behavioral Health Authority Northpointe Behavioral Healthcare Systems NorthCare Coordinating Agency Keweenaw COPPER COUNTRY CMHSP NORTHPOINTE GOGEBIC HIAWATHA Houghton PATHWAYS CMHSP Ontonagon Baraga Luce Marquette Gogebic Alger Chippewa Iron Schoolcraft Dickinson Mackinac Delta Five community mental health boards make up NorthCare. The emr roll out was in two stages. Pathways – the lead agency – went first and went live October 2008 – following an approximately six month implementation period. The other four agencies took advantage of Pathways’ learning and went live the following year, October of 2009. Both implementations suffered from the usual lack of resources, both in time and staff. Very little process management work was accommodated due to schedules and resources. Menominee 37 37

Timeline Pathways Implementation
Attempts to implement 6 Sigma met with resistance Saw ABAI 2008 talk on 6 Sigma and BSA Contacted WMU team 3 /08 – 12/08 Doc. Review Training Configuration Historical Entry Network readiness Billing Access ES Inpatient NorthCare Pathways BSA Consultation 12/08 – 4/09 Organization Several processes Performer Many disconnects identified Analyses of disconnects begun 03/08 – 12/08 - The Pathways implementation was done with a small team to allow for the speed in which it needed to be accomplished. 12/08 – 12/09 - With regional implementation, the project team split between supporting Pathways and pulling together the other agencies for the next implementation. BSA Analyses identified several disconnects within primary and support processes 12/09 – 4/10 – Primarily clean up, reacting to user needs and working through a growing realization that the workflow needed greater attention. Not only were business processes ill defined, but staff began to create their own solutions to issues as they arouse, leading to potentially different processes at each location – across fifteen counties. WMU 38 38

Helped us to identify areas for further analysis

Many disconnects were identified in clinical process – Authorizations was found to be a critical disconnect

Authorizations disconnect impacted process at multiple points

Performance Diagnostic Checklist
Antecedents and Information YES NO Is there a written job description? x Does the job description clearly identify the performance in question? Has the employee received adequate instruction about what to do? Are employees aware of the mission of the job and organization? If yes, can they tell you what the mission is? Are there job or task aids? If yes, are those aids visible while completing the task? Are there reminders to prompt the task? Is the supervisor present during task completion? Are there frequently updated, challenging and attainable goals? If yes, do employees feel these goals are fair? EQUIPMENT AND PROCESSES If equipment is required is it reliable? Is it in good working order? Is it ergonomically correct? Are the equipment and environment optimally arranged? Are larger processes suffering from certain incomplete tasks? Are these processes arranged in a logical manner? Are these processes maximally efficient? Are there any other obstacles that are keeping the employee from completing the task? KNOWLEDGE AND SKILLS- TRAINING Can the employee tell you what is supposed to be done? Can the employees physically demonstrate the task? If yes, have they mastered the task? If fluency is necessary, are they fluent? Does the employee have the capacity to learn to complete the task? PDC identifed several performer level disconnects for case notifications

PERFORMANCE SOLUTION CHECKLIST
ANTECEDENTS AND INFORMATION YES NO Add or alter job description? x Add or alter job model? Develop, alter, or articulate missions? Add or alter job/task aids? Add or alter reminders or prompts? Arrange for more supervisor presence? Add or alter goals? EQUIPMENT AND PROCESSES Add or alter equipment? Design, redesign, or eliminate process? Alter physical environment? KNOWLEDGE AND SKILLS- TRAINING Add or alter training? Add or alter fluency training? Alter selection procedures? CONSEQUENCES Add positive consequences for desired performance? Remove negative consequences for desired performance? Alter frequency, immediacy, and or certainty of consequences for desired performance? ? Add Premack reinforcers? Make effect of performance more visible? Add or alter feedback? Add or alter performance monitoring? Decrease response effort associated with the performance? Add negative consequences for undesired performance? Remove positive consequences for undesired performance? Alter frequency, immediacy, and or certainty of consequences for undesired performance? PSC identified several potential solutions for the disconnects identified in the PDC

Timeline Continued to conduct analyses on their own over summer and fall Realized they needed to pay more attention to their processes Needed more individuals involved in process analysis Pathways Implementation Regional Implementation Early Production 3 /08 – 12/08 Doc. Review Training Configuration Historical Entry Network readiness Billing Access ES Inpatient 12/08 – 12/09 Pathways support Document Review Training Configuration Historical Entry Network readiness Billing Analytics 12/09 – 4/10 Establish (and evolve) change management teams Identify disconnects & trends Prioritize needs Implement regional solution Optimize NorthCare Pathways Develop BSA training for change management teams Made good progress but ran out of time before analyses were complete BSA Consultation BSA Workshops 03/08 – 12/08 - The Pathways implementation was done with a small team to allow for the speed in which it needed to be accomplished. 12/08 – 12/09 - With regional implementation, the project team split between supporting Pathways and pulling together the other agencies for the next implementation. BSA Analyses identified several disconnects within primary and support processes 12/09 – 4/10 – Primarily clean up, reacting to user needs and working through a growing realization that the workflow needed greater attention. Not only were business processes ill defined, but staff began to create their own solutions to issues as they arouse, leading to potentially different processes at each location – across fifteen counties. 12/08 – 4/09 Analyze org, process, performer levels Identify disconnects 12/09 – 4/10 Analyze org, process, performer levels Identify disconnects WMU 44 44

Focus Shift Where we started Where we ended up
Analyze organizational processes to identify disconnects and create and implement solutions Partnership between organization (Pathways/NorthCare) and external consultants (WMU) Consultant led analyses Input from organization Where we ended up Develop a formal performance analysis process Organization led analyses Input from consultant Up to this point we had been focusing on analyzing and improving existing processes Now it was time to build this into the system by creating a formal performance analysis process w/ clearly defined roles and responsibilities Team members needed to be trained 45 45

Performance Improvement Workshops
Dual Purpose Train internal, cross-functional teams to become performance improvement experts Simultaneously analyze and improve existing systems issues Performance Based Instruction (PBI) Approach Guided Observation Guided Practice Demonstration of Mastery HM - okay from your perspective? Brethower & Smalley (1997) 46 46

SIPOC / F Is Process Map Best & Worst of Process Disconnects & Root Cause PDC & PSC, Should Process Map 47 47

SIPOC/F Diagram Purpose
Suppliers Inputs Process Outputs Customers Feedback List Suppliers Here List Inputs Here List Process Here List Outputs Here List Customers Here List Feedback Here Purpose Identify the internal and external variables that impact a process Suppliers Inputs Customers Feedback (Process and Customer) Identify the major steps of a process Benefits Provides a bird’s eye view of how work gets done Can be applied to any process Identifies factors outside of the process that impact and/or are impacted by the process Insert Process Step 1 Insert Process Step 2 Insert Process Step 3 Insert Process Step 4 Insert Process Step 5

Purpose Understand the current process & how it is performed Evaluate and improve operations Communication tool Benefits Clarifies and organizes information Quickly communicates big picture and details Identifies critical processes / steps and differentiate from noise Identifies improvement opportunities Identifies process stakeholders/contributors Contributes to justifying a business case Presents process from other points of view

Task, Decision, Document, or Data
Red Light / Green Light List all measures of the step List the length of time for step completion Describe the Tool that is used Check the step for improvement Activity Task, Decision, Document, or Data Tools Used (job aid, form, guidelines, equipment, etc.) Output (should be an input to the next task) Measure(s) (Quality, Quantity, Timeliness, Cost) Performer Duration Traffic Light Green Yellow Red What needs improving? 1 Eliminate step Alter step Automate step Performance specifications Task support Feedback Consequences Knowledge/Skill Capacity Measures G Y R Purpose To identify the steps making up the process under study To gather information necessary to improve the process Benefits Steps likely to require careful measures and monitoring Disconnects in the form of missing, redundant, or convoluted steps in the process Disconnects in quantity, quality, timeliness or cost of the process steps Complete the Process Map Analysis tool. Identify RED LIGHTS in the column provided. Green = “go” – this activity is serving the mission effectively Yellow = “slow down” – this activity is a cause for concern (usually because another process step is broken) Red = “stop” – this activity is broken and in need of a Critical Fix Then, within the table, circle the component of the process that seems to be the problem inadequate input activity is not well defined tools are inadequate output is of no value [no one uses it] measure not meeting standard no owner/doer takes too long Next, complete the Performance Diagnostic Checklist (PDC); see next section Once PDC is complete return to “What need improving” section Label the step List the output of the step Fill in “light” Identify the performer

Best/Worst Exercise Purpose Identify positive and negatives of:
Old Process Things we want to keep Things we want to discard New Process Things we want to create Things we want to avoid Purpose Identify positive and negatives of: The current system The proposed change/redesign of the system Benefits Keep what works and discard what doesn’t Guide development of should process Dams, 2010

Performance Diagnostic Checklist
Antecedents and Information YES NO Is there a written job description? Does the job description clearly identify the performance in question? Has the employee received adequate instruction about what to do? Are employees aware of the mission of the job and organization? If yes, can they tell you what the mission is? Are there job or task aids? If yes, are those aids visible while completing the task? Are there reminders to prompt the task? Is the supervisor present during task completion? Are there frequently updated, challenging and attainable goals? If yes, do employees feel these goals are fair? EQUIPMENT AND PROCESSES If equipment is required is it reliable? Is it in good working order? Is it ergonomically correct? Are the equipment and environment optimally arranged? Are larger processes suffering from certain incomplete tasks? Are these processes arranged in a logical manner? Are these processes maximally efficient? Are there any other obstacles that are keeping the employee from completing the task? KNOWLEDGE AND SKILLS- TRAINING Can the employee tell you what is supposed to be done? Can the employees physically demonstrate the task? If yes, have they mastered the task? If fluency is necessary, are they fluent? Does the employee have the capacity to learn to complete the task? CONSEQUENCES Are there consequences delivered contingent on the task? (PIC/NIC Analysis) Are they natural, programmed or both? Are they frequent or infrequent? Are they immediate or delayed? Are they certain or uncertain? Are there Premack reinforcers? I.e., Is there opportunity to work on more preferred tasks after less preferred tasks are completed? Do employees see the effect of performance? If yes How? Natural? Arranged? Do performers receive feedback on their performance? If yes, written or verbal or other? From whom? Direct or indirect? How often is the feedback provided? Is there performance monitoring? If yes, self-, supervisor direct-, or supervisor indirect? Is there significant response effort associated with the performance? Are there other behaviors competing with the desired performance? (PIC/NIC Analysis) Are there consequences for those other behaviors? Purpose Understand how human performance is affected by the work environment Identify potential performance improvement solutions Benefits Look at different aspects of the work environment Focus efforts on an identified area for improvement Avoid unnecessary training or consequences that may waste company money Determine if the performance gap is a result of a system barrier or truly a performance deficit Create solutions tailored to specific performance

PERFORMANCE SOLUTION CHECKLIST
ANTECEDENTS AND INFORMATION YES NO Add or alter job description? Add or alter job model? Develop, alter, or articulate missions? Add or alter job/task aids? Add or alter reminders or prompts? Arrange for more supervisor presence? Add or alter goals? EQUIPMENT AND PROCESSES Add or alter equipment? Design, redesign, or eliminate process? Alter physical environment? KNOWLEDGE AND SKILLS- TRAINING Add or alter training? Add or alter fluency training? Alter selection procedures? CONSEQUENCES Add positive consequences for desired performance? Remove negative consequences for desired performance? Alter frequency, immediacy, and or certainty of consequences for desired performance? Add Premack reinforcers? Make effect of performance more visible? Add or alter feedback? Add or alter performance monitoring? Decrease response effort associated with the performance? Add negative consequences for undesired performance? Remove positive consequences for undesired performance? Alter frequency, immediacy, and or certainty of consequences for undesired performance?

Who will monitor progress?
Should Process Action Plan Specify Design – Implement Disconnect Solution Who does what by when? Who will monitor progress? What are the measures? Purpose To identify the steps necessary for the ideal process Benefits Identifies the key steps needed for optimal performance Corrects for any disconnects found during the Is Process Map and Best/Worst exercises Creates a blueprint to guide the changing of your process to its ideal state

Sample Team Process Map
5/15/10 – JMP Output from workshop 2 – input to workshop 3. This is a map that was done in a breakout group in the workshop on paper, and then an admin put it into Visio after class. There were four teams and all four teams did a process map for the PEPS Change Management process. Once the Visio was complete, each team validated their map and had an opportunity to make changes to it. Claudia, Ralph and I added the little feedback bubble. Each of the other process maps were projected and discussed in the beginning of Workshop 3. Is it possible to use this slide as just an anchor for the workshop discussion in general? I am a little uncomfortable distributing details on disconnects and the analysis is still really very introductory anyway. You might share this fact and use it as an example of how this is not an exceptionally quick learning curve. Also, your candid perspective in working with us throughout the workshop process seems like it would be appropriate. From my perspective: 1 – The workshop series was an expensive endeavor when considering the time put into it by 20+ people. 2 – The authoring had input from the likes of me with the six sigma and your team, and then was delivered by a first class instructor. So we were very fortunate when considering the resources, and we still see slow absorption. This does warrant the six sigma type training where you are in class for weeks at a time, but that is not a reality here. 3 – The upside is that even if the skills are still early in the develop cycle, we are miles and miles ahead for this upcoming costing project. Plus, this was a major cultural breakthrough for the agency – investing in this type of employee development and in these types of empowerment tools. And it took some outspoken persistence and risk-taking to get here, but it was worth it. Do we want to add any samples of the work the teams have done? What are you looking for here? The work is very elementary at best … That’s ok Maybe pick one group and provide a sample from each workshop? Or follow a disconnect analysis that has led to a change in process? Maybe we could find a team’s work that improved over time, demonstrating that learning was occurring and that the analyses they were conducting were yielding useful information. RLO & CRJ – what do you think we should incorporate here? RLO – one slide on the reality of what it was and what it took CRJ – this is a cultural shift – learn, adapt, accept, use as skills are refined, deal with bumpy-ness until it becomes second-nature. 60 60

Next Steps Results Next Steps Local and regional solutions
CEO approves wider use of the tools Next Steps Continue to develop OBM skills within the organization Establish an operations management team specifically chartered to leverage these tools to deliver measureable results – this team reports directly to the CEO Partner with WMU to create sound measurement systems Can we give a couple of specific examples of measurement systems in development? We have some reporting in place in order to assess staff activity – direct services by clinician or program for example. We have analytics in audit that are designed to help us assess utilization management and access trends. Beyond descriptive analysis of activities, there isn’t much – so in development means not just from a practical perspective, like we are coding the reports, but from an entire design perspective, meaning we know to deliver quality services we need to measure X Y and Z and have built a system to do it. … see next question. For what expanded use has the CEO approved the tools? Do we have a specific area or issue? Ralph and I will be using the full array of tools to evaluate the clinical services delivery process. Our commitment is to reduce clinical cost by 10%. We are in the earliest stages of this. We are meeting with clinical leadership to present our approach. It is heavily reflected in the workshop materials you have seen from us so far. We’ll need to incorporate some six sigma measurement methodology such as critical to quality measurements and critical to process measurements as we go forward. We haven’t really addressed the BSA equivalent, have we? I think I remember that the number of attendees increased over time – is that correct? Maybe we mention it? I also remember that you guys thought the number of attendees would actually decrease over time – is that correct? It might be neat to show that the opposite was true. Initially we thought we would have 5 or 6 attendees to represent one project team – “unsigned documents team.” Then when we introduced it and asked for volunteers, surprisingly every PEPS team member but one (an admin support person) wanted to attend – that became about 20. Then halfway through, when we went to the RCM2 mode and needed more skilled RCM participation from NorthCare, we added three more people. I am not sure that would make a good visual, but seems like more of an anecdote… 61 61

Final Thought – IS versus SHOULD
Workflow (process) analysis and improvement occurred after EMR implementation Disconnects found are both process based and EMR system based Not ideal but still successful SHOULD Workflow analysis and change management conducted prior to EMR implementation Should reduce number of disconnects, but probably won’t eliminate them all together Need for analysis is constant – today’s SHOULD is tomorrow’s IS If you haven’t begun the process of implementing an EMR yet, we urge you to use OBM to analyze readiness in terms of your existing processes, how they will change, and what training and support will be required to successfully implement your system Steve Enge will now discuss implementation recommendations 62 62

Implementation Recommendations
Steve Enge, IT Systems Architect Kalamazoo Community Mental Health

Implementation Recommendations
Manage Expectations Leadership Project Management Process Driven Design Vendor / Product / Contract Technology Infrastructure Behavior Management

Implementation Recommendations Manage Expectations - ROI
Level of Analysis Individual Performer Process / Organization Process Improvement Regulatory Compliance Fund. Source Compliance Reduced Billing Errors Improved Productivity Reduced Cost of Service Outcomes Measurement Unified Organization Improved Decision Making Easier Quality Assurance Return Type Hard $$$ Soft Streamlined Workflow Reduced Data Redundancy Access to Historical Data — But Often Not — Less Data Entry Time at All Steps in the Process Point of Service Access Master Treatment Plans Improved Coord. of Care Improved Data Accuracy Improved Clinical Practice Outcomes Measurement 65

Return On Investment (ROI) (National Council for Community Healthcare)

Implementation Recommendations Manage Expectations
Typical Expectations Real World Realities Usually at the Organizational Level Not Always at the individual/task level The computer will do everything Will save money and reduce staff Will run on PDA, cell phone, pager Will make us HIPAA compliant Our systems will be paperless Will be working by next month We won’t lose any of our old data We’ll have data at our fingertips Vendor will take care of everything Will help us provide better care Computers follow instructions Capital & long-term investment required Bleeding edge is not always cutting edge HIPAA is an organizational challenge Not all paper is bad If we plan the work, we can work the plan We may not want all our old data Good data is hard work Few vendors are non-profit entities Better care through effective deployment It will be a long process no matter what Good project management can shorten it Data at your fingertips only if: The software enables Staff enter it when/where they should They will do what the contract requires

Implementation Recommendations Leadership
Executive Management Support is Essential Set the overall mission/goals Set a timeline with strict accountability Allocate Adequate Resources Communicate commitment … continuously Important Issues Understand the Perspectives of All Stakeholders A Team Based Approach is Best (only?) Way Corporate Culture is a Key Factor Impact on Financial & Human Resources Significant and Continuing Clinical Value Should be the Heart of the Project

Implementation Recommendations Project Management
Build the Team (Document with Written Charter) Define Implementation Scope and Expected Outcomes Project Plan – Detailed! Continuous Tracking Be Prepared to Adapt Contingencies My Be Required Slow Trigger Fast Bullet Communications Plan Process Analysis and Design Development Process Training Plan Rollout Plan

Implementation Recommendations Process Driven Design
Project Management Top Leadership Buy In Build & Empower Project Team Develop Project Plan Manage the Plan Development Process: RequirementsDevelopment TestingAcceptance Process Analysis and Design Communications Plan Process Analysis and Design Development Process Training Plan Rollout Plan Understand Current Process Technology Review: What’s Possible Design Desired State Process Design Solution Build And/or Configure Solution Requests For Information (RFI) Detailed Functional Speci- fication Request For Proposal (RFP) Evaluate & Select Vendors & Products Negotiate Contract Vendor and Product Selection

Certification Commission for Health Information Technology www. cchit
Certification Commission for Health Information Technology Non-Profit Industry Group Certifies EHR software applications Officially recognized by the federal government as a certifying body Certification Programs CCHIT Certified® Functionality, interoperability and security meets commissions criteria Preliminary ARRA: Meaningful Use Stage 1 certification criteria Ambulatory 2006 EHR Certification Inpatient 2007 EHR Certification Ambulatory 2007 EHR Certification Inpatient 2008 EHR Certification Emergency Department 2008 EHR Certification Ambulatory 2008 EHR Certification CCHIT Certified® 2009 Health Information Exchange Certification Preliminary ARRA 2011 certification: EHR Technology for Hospitals Preliminary ARRA 2011 certification: EHR Technology for Eligible Providers

Implementation Recommendations Vendor / Product / Contract
Shop Around Ask for (Several) References the Vendor Build and Maintain a Win-Win Relationship Product Consider only CCHIT Certified Products Don’t Buy on Price Alone Contract Get Early Legal Advice Tie Payments to Milestones – Contingencies! Termination Provision Warranties and Indemnities – Difficult but Necessary Performance Criteria Remedies for Failure Escrow the Product and Payments

Implementation Recommendations Technology Infrastructure
Everything the organization does should be driven by its Mission Mission The Mission is fulfilled through the development and execution of a good Strategy Strategy In turn, the Strategy is executed through the design and operation of effective Business Processes Business Processes Information Technology (in this case, EBHR) is used to enable the design and operation of new and improved Business Processes Enabling Technology (EBHR) Support Infrastructure The success of the processes and technology rely on a strong Support Infrastructure Investments in Information Technology can be quite costly We need to get a good return on investment in the form of more effective and/or less costly business processes Failure to provide an adequate Support Infrastructure can lead to limited return on investment So, investment in Support Infrastructure must be part of the overall Technology investment, and not an afterthought!

Implementation Recommendations Behavior Management
Prepare for Resistance to Change Stonewalling Non-Compliance Interference Typical Problem Areas Resistance to Teaming in a Hierarchical Organization Silo Mentality (EBHR directly challenges Silo stakeholders) Paradigm Shift: Words to Data to Words Dictation/Narrative Tradition (and Poor Typing Skills) Fear of Accountability Fear of Incompetence Invest In Communication Development Training Contingencies Integration vs. Specialization Standardization vs. Individualization Control vs. Flexibility and Efficiency Treatment Ideology Development Process: RequirementsDevelopment TestingAcceptance Subject Matter Experts Praise and Recognition Paid Time Off Link to Performance Evaluation System Link to Performance Pay Systems

Resources

Alphabet Soup (By Topic)
EHR: Electronic Health Record EBHR: Electronic Behavioral Health Record PHR: Personal Health Record CCHIT: Certification Commission for Health Information Technology CMS: Centers for Medicare & Medicaid Services SAMHSA: Substance Abuse and Mental Health Services Administration ONCHIT: Office of National Coordinator of Health Information Technology NOMS: National Outcome Measures (SAMHSA Measures for MH) TEDS: Treatment Episode Data Set (SAMHSA Measures for SA) MDCH: Michigan Department of Community Health (Analogous to Federal HHS) MHSAS: Michigan Mental Health & Substance Abuse Services Commission (Analogous to Federal SAMHSA) MHITC: Michigan Health Information Technology Commission (Analogous to Federal ONCHIT) MMBPIS: Michigan Mission Based Performance Indicators (Analogous to Federal NOMS and TEDS) HIPAA: Health Insurance Portability & Accountability Act ARRA: American Recovery & Reinvestment Act HITECH: Health Information Technology for Economic and Clinical Health Act HIE: Health Information Exchange NHIN: Nationwide Health Information Network (Network for nationwide HIE) RHIO: Regional Health Information Organizations (Building blocks of NHIN)

Alphabet Soup (Alphabetically)
ARRA: American Recovery & Reinvestment Act CCHIT: Certification Commission for Health Information Technology CMS: Centers for Medicare & Medicaid Services EBHR: Electronic Behavioral Health Record EBP: Evidence Based Practice EHR: Electronic Health Record HIE: Health Information Exchange HIPAA: Health Insurance Portability & Accountability Act HITECH: Health Information Technology for Economic and Clinical Health Act MHITC: Michigan Health Information Technology Commission (Analogous to Federal ONCHIT) MHSAS: Michigan Mental Health & Substance Abuse Services Commission (Analogous to Federal SAMHSA) MDCH: Michigan Department of Community Health (Analogous to Federal HHS) MMBPIS: Michigan Mission Based Performance Indicators (Analogous to Federal NOMS and TEDS) NHIN: Nationwide Health Information Network (Network for nationwide HIE) NOMS: National Outcome Measures (SAMHSA Measures for MH) ONCHIT: Office of National Coordinator of Health Information Technology PHR: Personal Health Record RHIO: Regional Health Information Organizations (Building blocks of NHIN) SAMHSA: Substance Abuse and Mental Health Services Administration TEDS: Treatment Episode Data Set (SAMHSA Measures for SA)

Key Resources HHS: http://www.hhs.gov/ SAMHSA: http://www.samhsa.gov/
NOMS: TEDS: Evidence Based Practice: CMS: HIPAA: ONCHIT: Exec. Order (2004): NCHIT: HIE: RHIO: NHIN: ARRA: HITECH: Healthcare Reform: MDCH: MHSAS: HITC: MMBPIS: CCHIT: Certification Commission for Health Information Technology: Meaningful Use: SATVA: Software and Technology Vendors’ Association:

Questions? Comments? Steve Enge – senge@kazoocmh.org
Krystyna Riley – Heather McGee –

Implementing Electronic Behavioral Health Record

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Implementing Electronic Behavioral Health Record

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