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.
Documentation speed jumps 360 percent
Compared to paper-based systems that depend on human memory, process, and judgment for completion of required elements of care that underlie specific diagnostic or billing codes, EHRs work behind the scenes, managing and presenting each client's information based on the role performed by defined system users. Starting with client intake information and an initial diagnosis, for example, MHCCI's EHR system helps pull the golden thread: ensuring a match between billing codes and work.
“The EHR links the billing to the discussion associated with it,” says Wilkerson. The result is far fewer human errors, far fewer rejected claims, and far more efficient treatments.
Because of the intensive involvement of front-line nursing and clinical staff with clients and client documentation, they were a logical choice to receive the first structured forms developed by Wilkerson's team and the first group whose work with the new process would be measured. Three quarterly measurements show, to date, that documentation time among these professionals fell, on average, from 11 minutes per session to just three minutes-a 360 percent improvement. According to Wilkerson, much of the improvement happened quickly, within the first quarter after the process change. He notes that documentation time, while down, does fluctuate based on the mix of forms that clinicians must complete during the quarter.
Figures 1A and 1B. Using the capabilities of their EHR system, MHCCI's process improvement team converted a general-purpose, paper-based progress note into a “structured” electronic form, in this case, tailored to the needs of a registered nurse. There's no need for all of the “fill in the blank” items at the top and bottom of the paper form since the structured electronic form relies on the EHR to store related information about the client, diagnosis, appointment, and clinician involved. Click here to view a larger version of Figure 1A. Click here to view a larger version of Figure 1B.
Figures 2A and 2B1 A medication training note on paper (2A) and in structured electronic form (2B). The EHR presents this note to the clinician during appointments when medications are prescribed as part of a client treatment plan. The note guides the clinician through the discussion, presenting discussion points associated with a related Medicaid billing code. By tying the details of electronic forms to the client's treatment requirements, the EHR helps MHCCI tie “the golden thread” that links diagnosis and treatment activity to the documentation required for reimbursement. Click here to view a larger version of Figure 2A. Click here to view a larger version of Figure 2B.
A surprise for clinicians
Wilkerson explains that, during its introduction, the concurrent documentation approach required clinical staff to interact with their clients in a new way. Clinicians would make notes during the course of an appointment, while a computer display screen enabled clients to observe (figure 3). When this change was piloted, it proved unsettling for some. “My biggest surprise with all of this was the initial resistance by some staff members to have clients read what was said about them. That piece threw me for a loop initially,” Wilkerson recalls.
But he could see where the clinicians were coming from. “It was a new process, and if a client disagreed with what the clinician typed in, a discussion had to occur. The differing points of view had to be brought together.”
Ultimately, it took time to develop consensus about how best to introduce the process to clinicians and clients alike. Wilkerson sums up the discussion like this: “The key to concurrent documentation is being able to document the information with the client. Most clinicians complete notes at the end of a session, summarizing what was discussed and learned, what the patient will be working on. So, we say to the clinician, ‘You're going to do [the notes] as you learned, but now, you're going to enter them in the computer at the same time that you give them to the patient.’ So, when the clinician is ready, he or she might say to the patient, ‘Let's go over here and draft our progress note, our summary, together.’”
Common ground with clients
“There are,” he continues, “a lot of positives that come out of that.” In addition to the comfort of clinicians being able to finish work sooner, Wilkerson says, “I often hear from staff members that they had one clinical impression, but that the client was thinking differently. Sharing [during the summary note process] helped to drive a different understanding, a common ground of understanding for the therapist and the patient.”
Clients have also had their say, says Wilkerson. “We've heard a lot of feedback that clients feel more involved-the process definitely supports a recovery-focused approach,” he notes. Quarterly surveys of client satisfaction/clinician engagement show a strong positive response.
Going on the road
Recently, the concurrent documentation effort has gone mobile, enabling staff to document the provision of services outside the office. Once again, the process was kicked off with a presentation by MTM Services, highlighting the fundamentals of conducting offsite or mobile meetings, inviting client participation in the progress notes, transmitting client information securely, and managing mobile information technology.
“Now,” says Wilkerson, “we can meet with clients and do concurrent documentation anywhere, provided that [the location] is HIPAA appropriate.”
Figure 3. Client, at left, with clinician. MHCCI's concurrent documentation process encourages the client (left) to work with the clinician (right) to summarize their own clinical progress. A survey of hundreds of clients over a nine-month period found that 82 percent of clients rated the concurrent documentation approach as “helpful” or “very helpful” to their treatment, while over 90 percent said it made them feel “involved” or “very involved” in the treatment process.
Presently, the team is continuing development of structured forms to be used by MHCCI's doctors. Their concerns are unique, says Wilkerson, because “in addition to doing a progress note on an individual, which is what everyone else has to do, the docs have to update a diagnosis on every set, update labs on every set, and update meds on every set.” He says that the team is “looking closely” at the process for ways to make it easier and faster to use, to “ensure that the docs aren't just typing everything in.”
Material, process, and staff savings
“We're not completely paperless, but we are working towards it. It's a long journey,” says Wilkerson, who took a moment to explain the value of “going paperless.”
While there are “obvious savings, like paper, that you don't have to buy,” Wilkerson says that eliminating “the movement of paper” in the office offers the kind of savings that accountants really notice. “If something is printed, you pay for a staff member to get up, pick up that piece of paper, sign it, and run it through whatever submission or management process you have. Then, when that's over, you pay someone to file it.” Reducing the movement, and inevitable loss, of paper records means that MHCCI was able to free administrative staff for other responsibilities in the office or for transfers elsewhere in the health system. “We didn't let anyone go, but we have reduced expenses,” he says.
Just as important, the switch to concurrent documentation has reduced stress. “One of our staff members said it was ‘a life-changing event,’” Wilkerson recalls. “She explained that since progress notes are due at 10 a.m. the next day, if she was unable to finish her progress notes before leaving the office, she would worry about starting the next day behind, having to catch up.” Now, he adds, “we encourage people to ‘work your work schedule and go home.’ It shows that, as an agency, we recognize there's more to life.”
Behavioral Healthcare 2010 September;30(8):32-37