How many times have you made a declaration to become a “recovery” organization and trained your staff in new principles, only to see little change in actual practice and outcomes? There's no shortage of possible reasons: The staff didn't “get it,” the trainer was boring, the consumers are sicker than everyone else's, and so on. However, there's often a more likely culprit: documentation that requires staff to focus on a consumer's weaknesses and challenges rather than his or her strengths.
Such documentation compromises the efforts of recovery-trained staff because it prevents them and the consumer from utilizing this approach. Instead, staff can become frustrated and give up trying to fit new “recovery” learning into old structures. The documentation process “undoes” the learning.
This is a big problem! Documentation contents and processes must be built around our organizations' values if we want them to reflect and reinforce the principles and practices we instill in our workforce. When they don't, we lose traction and waste effort, time, and money.
So, all we have to do is create a new recovery-based documentation system! A simple task, right? No, say organizational leaders. Many have already invested in electronic health record (EHR) systems, and, for the most part, these systems were not designed and built to reflect and reinforce recovery practices. Adapting an existing EHR system to support recovery can be a daunting task, even if it can advance recovery values and fast-forward culture change.
We've been watching a company go through this process and want to share their story so you can learn from their experience. Recovery Innovations (RI), a multi-state non-profit, is dedicated to producing recovery outcomes. They face many of the same organizational challenges noted above in terms of developing and completing documentation that reinforces the values that guide their service delivery.
RI developed an in-house electronic medical record in the mid 1990s. By 2000, this EMR was in full use at the time when its CEO, Gene Johnson, committed RI to a recovery-oriented transformation of its services and culture. As the organization learned the implications of a recovery approach, it soon found that its home-grown EMR did not support recovery practices. RI staff agreed, noting that it was very frustrating to translate recovery-focused content onto forms that didn't recognize or accommodate recovery principles. All agreed that an overhaul of RI's EMR system was necessary.
Almost immediately, the company discontinued using much of its existing EMR in favor of a hardcopy system that reflected and reinforced recovery values and practices (Figure 1). To automate access to the hardcopy documents created by this system, RI adopted scanning and imaging technology that enabled electronic document filing and retrieval.
Figure 1: Principles of a recovery-focused documentation system
While RI's hardcopy documentation supported staff and consumers in recovery, managers knew it was a stopgap measure. After considering the then-available systems that could support a recovery-focused approach, RI decided to develop its own new EHR system. Gene and his IT team knew that this commitment could be time-consuming and expensive, but they believed it would more than pay for itself by reinforcing RI's recovery-focused culture and supporting the values and outcomes RI used to measure success.
The next challenge was to transform the recovery-focused hardcopy record into an electronic record process, based on a standardized process of recovery called Recovery Coaching. Adopted years earlier by RI, this approach is built around a simple, seven-step conversation that effectively supports the recovery process (Figure 2).
Figure 2: The Recovery Coaching approach
The assignment for the IT team was this: Use the Recovery Coaching protocol to create computer screens, resulting in documentation that matched with the recovery steps staff were trained to use. Of course, the documentation process also had to be reimbursable and audit-proof. A daunting assignment, to be sure, but Gene has a way of believing things can happen and somehow they usually do.
The IT team, under the direction of Jeff Norris, set some more explicit objectives:
Reinforce the training received by staff in the Recovery Coaching approach and the consistent use of recovery-focused language.
Promote participation and ownership by the consumer by allowing the consumer to securely access their EHR, either alone or with a staff member.
Meet audit standards.
Encourage partnerships between staff and consumers.
Be transparent and easily accessible for both staff and consumer in a variety of ways.
Promote self-direction.
The IT team went to work developing the new system using a web-based language. After a series of tests and changes, the new system was installed in two new crisis alternative programs. The system is up and running and in one setting it is being used with laptops in people's homes.
The screen below (Figure 3) illustrates how the process begins. You can see how the “Recovery Journey” starts by building the “Recovery Partnership” using Recovery Coaching. The screens are completed with the consumer. Sometimes the consumer does the typing.
Figure 3: Screen display in recovery-focused EHR system
The “Recovery Journey” continues with “Getting to Know You,” a group of discipline specific tools: Physical Health Screening, Wellness Consultation (psychiatric evaluation), Telling My Story (social history), and Substance Use. “Recovery Solutions” is the treatment plan and the “Recovery Journal” contains the progress notes. Throughout the sequence of screen displays, the person's accomplishments and strengths are kept in view to reinforce the empowerment and resiliency started in the Recovery Partnership.
It is possible to have an EHR that reflects and reinforces a recovery process and culture. We hope that this example provides good ideas of how one organization accepted the challenge. Let us know if you have other ideas that can help all of us move beyond where we are today.
Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's editorial board. William A. Anthony, PhD, is director of the Center for Psychiatric Rehabilitation at Boston University. Behavioral Healthcare 2010 January;30(1):22-24