Documenting a recovery approach: Recovery Innovations adapts documentation to fit operations and culture.
Subject: Electronic records (Usage)
Information management (Methods)
Psychiatric services (Human resource management)
Psychiatric services (Information management)
Authors: Ashcraft, Lori
Anthony, William A.
Pub Date: 01/01/2010
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2010 Vendome Group LLC ISSN: 1931-7093
Issue: Date: Jan, 2010 Source Volume: 30 Source Issue: 1
Topic: Event Code: 280 Personnel administration; 260 General services Computer Subject: Information accessibility; Company personnel management; Company systems management
Product: Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 220203606
Full Text: How many times have you made a declaration to become a "recovery" organization and trained your staff in new principles, only to sec 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 arc 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 hard-copy 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

A recovery-focused documentation system must not only be structured around key principles associated with recovery, but must also be presented, developed, referenced, and used in a way that creates a strong counselor-consumer relationship and empowers the consumer striving toward recovery. The recovery principles to be embodied in a documentation system include:

Participation: The document design and interface must enable the consumer to participate in the development of the content, for example, by writing their own recovery plans and creating their own progress notes.

Progress: Through their structure and questions, the forms must reflect an expectation of progress and invite exchange about the consumer's effort and actions toward recovery.

Strengths: The sequence used to develop the documentation must begin with detailed consideration of the consumer's strengths, the role of these strengths in the recovery process, and details of how the challenges of recovery create learning and growth opportunities for the consumer.

Self-directed: The documentation and the manner in which the consumer interacts with it (reading, writing, typing, and editing) should reflect the fact that the consumer is the expert in his/ her own life and the major driver of the document's content and updates.

Accessibility: The documentation's design and storage must allow consumers fast, easy access and regular opportunities to contribute updates, edits, and measures of progress. In addition to these principles, well-designed EHRs (hardcopy or electronic) must meet audit standards and allow for federal reimbursement in a fee-for-service model.

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).

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.


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.

BY Lori Ashcraft, PhD, AND William A. Anthony, PhD

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.
Figure 2: The Recovery Coaching approach

Clearing             The practitioner prepares
                     to be fully present.

Connecting           The practitioner is intentional about
                     forming a positive relationship.

Empowering           The consumer is empowered to take
                     the lead in his/her recovery.

Planning             The consumer is supported as
                     he/she recalls, considers, and
                     develops a desired path to recovery.

Considering: What    Issues or obstacles that could threaten
can get in the way?  recovery are identified.
Building resilience  Practice addressing issues
                     or obstacles in ways that
                     advance and strengthen recovery.

Personal             Practitioner and consumer review
development          their work together and
                     commit to further work.
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.