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Self-creating an EHR system

January 1, 2010
by Paul Stieber, MA, MBA
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Spurred on by Y2K fears, this Chicago-based center built its own

By pioneering approaches in technology development over the past 10 years, the Community Counseling Centers of Chicago (C4) has strengthened its ability to improve quality of care, productivity, regulatory compliance, and staff satisfaction.

As most organizations were so intensely doing at the time, C4 thoroughly evaluated its existing information technology (IT) plan as the year 2000 approached. From its assessment, C4 concluded that the third-party billing software it used needed to be replaced because of significant concerns over its compatibility with Y2K requirements. Moreover, its vendor showed no intention of enhancing the system to meet C4's growing vision of having a fully integrated electronic health record (EHR).

Determined to find a solution that aligned with its vision, C4 reviewed the product offerings and outcomes of other large software vendors in the behavioral healthcare field to identify an alternative selection. Frustratingly, the end result of this assessment was that no vendor seemed to offer a product line that fully aligned with the organization's strategic plan. This caused C4 to consider whether its expectations were unrealistic or it would need to create its own solution to improving its operations to the degree outlined in its vision.

In-house talent

The idea of building a system in-house had tremendous inherent risk, in that the agency would depend on its existing and untested personnel to actualize its vision. As it turned out, evaluating the current system and leading the replacement project became my responsibility. As a former clinician, I had come to the organization to coordinate its utilization review program, based on my professional training in statistical analysis and evaluation. Gradually taking on a lead role in structuring the organization's approach to systematically collecting its data into meaningful databases that could be used for reporting, billing, and analysis, I introduced C4 to its first technical infrastructure. I then oversaw the organization's billing department and, eventually, its information systems department.

Years before my employment, C4 had understood the importance of standardizing its clinical procedures and processes for data collection; these methods had been implemented and maintained largely through the work of Director of Clinical Records Noemi Rivera, RHIA. The manual clinical records processes implemented by Rivera were early identified as key to C4's growing movement toward developing its own EHR system. Through the Target Cities Project funded by SAMHSA in the mid-1990s, C4 had been responsible for the development and administration of Chicago's portion of the computer system and network project. Through that opportunity, C4 had been introduced to the exceptional skills of computer programmer Cheryl Moloitis, MA.

By using Lotus Notes and Lotus Domino technologies, Moloitis had firmly and innovatively demonstrated how C4 could customize software technologies to meet its needs. This early work with Lotus Notes only encouraged C4 to more confidently consider its internally developed approach.

The plan

Conscious of the commitment, leadership, collaboration, and labor needed to take such a bold step, C4 conceived of an internally developed software solution. It conceptualized an automated record that prevented services from being entered that did not have all the required authorizations, staff credentials, clinical content, and other required documentation. It envisioned a system that eliminated clerical entries between service delivery and billing. It conceived a method whereby clinical forms would be electronically signed and stored online, thus avoiding the printing and storing of medical records. It planned a financial system in which charges would be posted to a uniquely designed accounts receivable system, where collections and rejections could be posted automatically by simply uploading billing outcome data. Furthermore, C4 set as its software development goals:

  • Improving quality of care;

  • Increasing revenue;

  • Reducing support costs related to billing and clinical record upkeep;

  • Minimizing billing rejection;

  • Eliminating risk of recoupment of previously paid charges;

  • Providing a paperless environment;

  • Reducing clinical liability by advancing agency best practices;

  • Reducing clinician documentation time; and

  • Developing reports that prompted and encouraged managers to improve operations.

Early identified as key to the development of an in-house EHR system was building a network of unified teams of senior staff/experts who would design the content and functions of each unique application. To this end, distinct teams were developed to construct the major applications: intake/assessment, treatment plan, progress notes, transfer and discharge, employee clinical credentials, billing, accounts receivable, and management reports. Each team's recommended design had to to complement and integrate with the other teams' work. To ensure systematic design integration, each team included at least Noemi Rivera and myself, and we met twice weekly to review the progress of the teams toward meeting the agency's vision. Together we worked with Cheryl Moloitis to design the system that she would eventually program.