Mental Health Centers of Central Illinois (MHCCI), an affiliate of Memorial Health System (Springfield, Ill.) is a private, not-for-profit provider of behavioral health and rehabilitation services, serving some 10,000 individuals from multiple locations in six counties that include the cities of Springfield, Lincoln, and Jacksonville.
A longtime user of electronic billing and an early adopter of electronic client records, MHCCI continues to invest in health information technology applications. Since 1989, when its first billing system went live, it has evolved a sequence of products offered by The Echo Group (North Conway, N.H.), most recently into the Clinician's Desktop/EHR package.
Burdensome, costly paperwork
In early 2009, MHCCI undertook an agency-wide operations review in response to plunging national and state budgets for behavioral health services. A few months later, in May, the agency's director of quality management and outcome evaluation, Jim Wilkerson, was asked to join with staff to address a major issue from the review: the growing burden and cost of state-mandated paperwork required for reimbursement of care to publicly funded behavioral health patients.
“Due to financial conditions in Illinois, we were looking at ways to increase revenue, decrease staff stress, and decrease paperwork load. Our staff told us that they had a lot of paperwork to do, something that we well knew, and it became a big discussion,” Wilkerson recalls. “That's when we came across this concept of concurrent documentation (CDoc) and we thought, ‘Ah, that's a good idea, to work the same way that medical doctors do, charting the entire time [with the patient]. Can we figure out a way to make this happen?’”
“How can we make everything work together?”
With initial concurrent document training and strategic direction from MTM Services (Holly Springs, N.C.), Wilkerson and his team started the project by understanding the time expended by staff on clinical documentation. At the time, he recalls, “We were really in the middle of implementing the EMR,” noting that the team was actively working on plans to convert important, paper-based clinical documents (client assessments, treatment plans, progress notes, and more) into easy-to-use electronic forms. Immediately, he explains, “We started thinking: ‘How do we do stuff?’, ‘How does the EMR do stuff?’, and ‘How can we make everything work together?’”
Within that thinking was an important realization: The EMR could help, but it wasn't a silver bullet. “Everyone knows that if you bring up an EMR, that doesn't mean less paperwork,” says Wilkerson. “Less paper, but not less ‘paperwork.’ So we were looking for ways to reduce the time that staff spent documenting.” A pilot study found that, for every one-hour appointment, clinicians typically would spend 11 minutes documenting afterward. “When you add that up, that's a whole lot of time spent documenting, instead of with clients,” says Wilkerson.
More documentation, but less typing
So, the challenge was not only to “convert” paper-based documents to electronic form, but to rethink and redesign them based on the requirement that they reduce the overall workload and that they be displayed, completed, and stored in the context of a ‘live’ treatment appointment. To accomplish this, the team decided to use “structured” electronic documents.
Compared to typical paper documents, such as progress notes, where a question may be followed by a blank answer box (for writing or typing), Wilkerson says that “a structured progress note lays out a variety of things-fields, boxes, check-offs, numbers-then flows you through them to ensure that you complete them.” The object is to simplify and speed up the documentation process by recording the maximum amount of information, consistently and repeatedly, with the minimum amount of typing.
While the movement of hand across paper makes it easy to cram a lot of information onto a few multi-purpose paper documents, Wilkerson's team found that reducing paperwork electronically would require more, not fewer, forms. They created a series of structured forms, each geared to specific tasks and particular users. “Theoretically, you could use one [structured form for all], but the key is to make it efficient for each person who's using it-that's why there are multiple progress note forms.” (See figures 1A, 1B, 2A, and 2B.)
Following “the golden thread”
Through logic capable of locating and associating thousands of diagnoses, diagnostic codes, treatment requirements, related treatment codes, and countless other bits or bytes of information, EHRs help providers coordinate activity efficiently around what consultant MTM Services calls “the golden thread” of treatment.
The golden thread begins with the patient assessment (identified needs), then pulls through the treatment plan (interventions and goals) to ongoing progress notes (patient efforts, services provided, progress made). And, it is golden because, if accurately followed through, the documentation that supports each decision, intervention, or patient progress note contributes to a complete record of patient care, error-free and ready for reimbursement.