A couple of months ago in our January Views column, I touched on the learning curve that's inherent in the adoption of electronic medical records (EMRs) and other information technology. It's a curve that can turn into the classic “hockey stick” shape as an organization's members struggle to understand the possibilities of technology and link it to their needs through a commitment to system selection, implementation, and training.
After that steep learning curve, there's often a welcome surprise as users begin, one by one, to “see the light” of how, after all their hard work, information technology can not only help accomplish organizational goals, but can be harnessed to make their work a little easier, a little more organized, and considerably more successful.
Will Walser, CIO of Colorado's Jefferson Center for Mental Health (JCMH), near Denver, reflects on a year-long implementation process in his organization, which involves 250 clinical and 80 administrative staff providing $30 million in services to 10,000 consumers annually.
In 2004, Walser confronted an aging, first-generation EMR and a decision to upgrade or replace it. Rather than risk upgrading the old client/server system, a process he likened to “changing the engine on an airplane in flight,” Walser and his colleagues opted for a new system built around the TIER EMR platform developed by Sequest Technologies (Lisle, Ill.).
JCMH's implementation continues to use its established client/server model, with the TIER application hosted at servers at the organization's administrative office and distributed via a high-speed, virtual, private network. However, the organization's remote users experience a web-like application, with the EMR program delivered through a relatively simple “thin client” program called Citrix that operates within a web browser on the user's desk. Users access EMR and billing information through a series of TIER electronic forms delivered by Citrix. Data fields within the forms feed into client records in the TIER database.
Walser says that delivering the forms through a web-style program like Citrix “gave us a lot of flexibility. We can log on from almost anywhere via the Internet. Basically, we deliver a screen on the user's desktop and data transfers over our intranet.” Flexibility was vital since JCMH's operations reach far beyond its eight hardwired offices. The system also reaches to 20 counselors working in regional elementary, junior high, and high schools, as well as professionals at nursing homes, group homes, and other sites in the community.
But continuing the client/server approach wasn't an instant hit with remote users, Walser recalls. “Early on, one of our remote users noted that, with a central database, ‘If you go down, then I go down, and that's not acceptable, is it?’ The user was right.” JCMH decided to back up its database and servers with a generator to ensure remote users would stay on line. “Later on, after we went live, we had the same problems with phone lines going down. So, instead of backing up our T1 line, we put a broadband cable modem in their offices. It didn't replace the lost capacity, but it kept them going on the system.
“We consider Sequest's billing module part of our EMR. Part of the EMR generates bills to payers and clients. We have our own general ledger system and human resources system. You can't run an EMR without having some components of those systems interfacing them. For example, you've got to have your licensure and credential information interfaced so that you can demonstrate that you meet payer requirements.”
Implementing EMRs can bring much efficiency to mental health and substance use treatment providers. But implementation can also bring about important and sometimes uncomfortable process changes-changes that clinicians may dislike or resist at first, says Walser. “Clinicians' biggest concern is about the requirements-from external and sometimes internal entities-that they must meet to generate complete documentation.” He explains that many providers adapted readily to typing in patient information during the course of the patient visit. However, some of those who have the habit of entering notes after service have not fully adapted yet.
While the EMR makes it easier to recognize and complete the requirements for service, he says that the system's ability to present so many variables means that “clinicians are confronted with the total load of documentation requirements needed for the patient. While this ultimately makes for a far faster billing and claims process-since it can eliminate a lot of administrative work downstream-confronting that load can be daunting.”
Translating the many needs and requirements associated with a client record into an electronic format is something of an art. In this area, issues typically arise as many professionals see that blending various needs, preferences, and variances into a single client record exposes small, but important differences. According to Walser, three concerns stand out in the development of data entry forms for an EMR:
Order of data fields. “Sometimes if you're using paper forms, you have fields arranged in a particular way. But translating those form fields into an electronic form is tricky, since you often find the forms used don't always follow with the processes.”
Mandatory data fields. The differing needs of internal groups, as well as the differing and changing needs of payers, may result in differences about what is considered “required” data in the EMR. These may result in some data fields being changed to “required,” or in the addition of new fields of “required” data.
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