Not many years ago, Texas state officials found that addiction treatment provider organizations’ clinical care documentation was dangerously inconsistent and incomplete. According to state records, 42 of 63 patient charts evaluated in a 1999 random review included no evidence of a diagnosis or listed a diagnosis inconsistent with the client's level of care or length of stay.
Less than a decade later, the Web-based electronic health record system that guides both clinical treatment and billing for the state's addiction treatment providers stands as a model both within Texas and nationally. This turnaround, driven originally by a state agency that hardly had been considered a model of efficiency at the time, occurred through a carefully phased process of automation that tried never to lose sight of users’ needs.
As a result, the Texas Department of State Health Services’ Behavioral Health Integrated Provider System (BHIPS) received a 2006 Nicholas E. Davies Award of Excellence in the Public Health category. The Healthcare Information and Management Systems Society (HIMSS) awards the annual honors for innovative uses of information technology in healthcare.
The description of BHIPS's functionality required a full three pages in DSHS's 17-page application for the Davies Award. The Web-based system governs all clinical, financial, and quality improvement functions for the addiction services provider organizations under contract with the state to provide publicly financed care. The state department's deputy commissioner considers the system's comprehensiveness an essential element to BHIPS's success.
“A critical juncture occurred with the decision to connect the electronic record to the billing system,” says DSHS's Dave Wanser, PhD. “It was important to connect doing the work to getting paid.”
The development of BHIPS parallels a larger effort to transform health and human services state agencies to improve efficiency—an effort marked by the consolidation of 12 state agencies into 4 departments. One of those four is the Department of State Health Services, created through a merger of the state's public health, mental health, and substance abuse agencies.
The latter of those three former agencies, the Texas Commission on Alcohol and Drug Abuse (TCADA), had been under a great deal of scrutiny in the 1990s over its program and spending accountability. At the time, agency officials had begun to discuss ways in which to ensure better continuity of care in publicly funded addiction services. The agency's clinical director took an idea that started as an online case management system and asked, “Why not do the whole clinical record and do it in a Web-based system?” recalls Dr. Wanser, who was at TCADA at the time.
TCADA remained committed to several important concepts during early development of the electronic record, knowing that it would need to obtain provider organizations’ buy-in for the effort to succeed. “We were committed to the concept of ‘no redundancy,’” says Dr. Wanser. “We never wanted to have a situation where a clinician had to enter something in more than once.”
Also, knowing that clinicians might balk at having to enter in so much more client data than they had been used to recording, state officials kept their focus on making sure the data collection efforts were tied to improving practice, Dr. Wanser says. Today, that plays out in provider organizations’ ability to generate dozens of reports from the system to inform their quality improvement initiatives. It also helps that the state's contracted substance abuse providers have begun reporting on a consistent set of outcome and performance measures, making it possible to conduct valid comparisons between organizations.
BHIPS's features run the gamut from online progress notes to discharge reports to a waiting-list screen to automated reminder messages for clinicians. But Dr. Wanser considers the system's assessment tools among the most critical elements for broadening the vision of treatment and guiding treatment planning. BHIPS includes a sound mental health assessment that has allowed addiction clinicians to offer a more integrated behavioral healthcare plan.
“We’re raising the standards of practice, and saying that treatment of co-occurring disorders is a part of what we do,” Dr. Wanser says.
In addition, as issues are identified in the assessment, BHIPS automatically records them as part of the treatment plan. This has forced clinicians to think about their services on an entirely different level, incorporating issues such as trauma, homelessness, and family violence into their efforts to help clients make progress, Dr. Wanser says.
But these requirements for provider organizations in using the system were not introduced all at once. The entire process was phased, with the online assessment introduced first. State officials put the assessment piece up on the system and then monitored its use. Once about 30% of its funded provider organizations were assessing clients using the electronic tool, the state required use of the online assessment and then moved on to treatment planning in the same fashion, and so on.
In addition, the state established several mechanisms for ongoing provider feedback. It created an online chat room where system users can help one another. It staffed a telephone help desk for provider organizations, manned first by IT professionals but later by program staff when it was determined that this role was not an efficient use of IT experts’ time, Dr. Wanser explains.
The state used a combination of federal and state monies to build BHIPS. According to DSHS's application for the Davies Award, about 85% of spending on BHIPS came from federal block grant funds, with state general funds accounting for the rest.