Implementing an EHR: a life-changing experience: first, learn as much as you can, then prepare to learn a whole lot more.
Subject: Electronic records (Usage)
Psychiatric services (Technology application)
Psychiatric services (Management)
Author: Grantham, Dennis
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: 200 Management dynamics Computer Subject: Technology application; Company business 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: 220203604
Full Text: This article is the first in a series focused on how information technology is changing the process of behavioral healthcare delivery.

The remarkably ambitious and detailed Health Information Technology (HIT) infrastructure outlined by the Office of the National Coordinator is so vast in scope that it is difficult to comprehend. In a nutshell, it envisions that each patient has an electronic health record (EHR) that consists of a series of smaller record segments (sometimes referred to as electronic medical records, or EMRs) generated and held by individual provider offices such as primary care, surgeon, or gastroenterologist. A special segment of the EHR--designated with special privacy protections outlined by the HIPAA Privacy Rule (42 CFR, Part 2)--would contain electronic records associated with behavioral health or substance abuse treatment.

Eventually--maybe in five years, maybe more--medical providers could access EHRs for their patients via secure healthcare information exchanges (HIEs) that make it possible for a provider to view all relevant aspects of a patient's health record in real time while planning or delivering care. The idea is to enable providers to integrate all forms of care more completely and accurately, making concepts like the medical home possible. So, finally, perhaps behavioral health and primary care providers can fully coordinate treatment for common, co-occurring medical/behavioral disorders and end the awful, 25-year disparity in life expectancy for publicly treated behavioral health consumers relative to the general population.

"Information should follow the patient, and artificial obstacles--technical, business-related, bureaucratic--should not get in the way," says David Blumenthal MD, National Coordinator for HIT at the U.S. Department of Health and Human Services. He adds, "Exchange within business groups will not be sufficient--the goal is to have information flow seamlessly and effortlessly to every nook and cranny of our health system, when and where it is needed, just like the blood within our arteries and veins meets our bodies' vital needs."

Of course, there's little about the information flow in many behavioral health facilities that is seamless and effortless today. And the thought of seamless and effortless exchange between providers--which assumes interoperable EHRs--is even more challenging to comprehend.

So where, within such a vast and ambitious vision, can a behavioral health provider even begin to begin?

A number of these questions were answered at an October 2009 Open Minds seminar held in Arlington, Va. The seminar, "Best Practice Models for New Software Implementation," brought together industry analysts, EHR users, and a group of those from the field who were considering, selecting, or in early-stage implementation of EHR software.

Dennis Morrison, CEO of Centerstone Research Institute of Bloomington, Ind., suggested that "we must become operable before we become interoperable," noting that healthcare IT funding and development lags behind that of other industries and that behavioral healthcare is even further back. For most behavioral health providers, that means evaluating and ultimately adopting some form of EHR. Without this decision, little of the HIT infrastructure or vision makes sense or adds value to the field.

There are plenty of hurdles, to be sure, ranging from the release of the behavioral health EHR "meaningful use" criteria that govern potential eligibility for ARRA reimbursements (scheduled for July 2010), evolution of interoperability data standards, and very local concerns like where behavioral health providers are going to get the money to pay for an EHR.

While those factors get sorted out, it doesn't cost too much to think about the things you can do to maximize your chances of selecting and successfully implementing an EHR system.

"It's a lot like getting married"

Often, software selection and implementation is thought of as a marathon to be paced or a project to be managed, but selecting and implementing an EHR is considerably more. "It's really a lot more like getting married," says Jonathan Evans, CEO of Safe Harbor Behavioral Health in Erie, Pa. "It costs a lot to get in and if you don't do it well, it will cost you a lot of pain and a whole lot more money to get out."

But equating software to marriage? Really? The thing that makes EHRs different is the fact that implementing them is so much a people process, as dependent on emotion, chemistry, values, and relationships as on financing and logic--maybe more so.

One of the pithiest explanations of the unusual dynamics of EHR implementation is contained in Planning your EHR System: Guidelines for Executive Management, a still very current whitepaper produced by Mental Health Corporations of America, Inc. (MHCA) of Tallahassee, Fl., and the Software and Technology Vendors' Association (SATVA) of New York City, in 2006. (1)

The whitepaper warns: "Try as you might to determine your organization's specific needs and to evaluate the ability of software solutions to address those needs, it is only after you start implementation that you will begin to understand that what you really need is not necessarily what you thought you wanted and that automation of some organizational processes will produce some new needs and eliminate many old ones." (2)

With obvious exceptions, this sounds almost exactly like a marriage that is followed by a great deal of disillusionment. Now, Evans' words sound more apt.

Who's in the driver's seat?

The very nature of specific community-based behavioral healthcare organizations, whose success so often traces back to the energy of a handful of unique people, doesn't seem to square with the idea of interoperability and standardization.

The SATVA/MHCA whitepaper captures and measures this distinction by outlining two approaches for EHR "engineering" and implementation:

* Organization-driven re-engineering assumes the uniqueness of each organization and stresses a customized approach in which EHR software is built around the uniquely successful processes and practices that exist in the organization. (See our feature, "Self-creating an EHR system" on page 26.)

* Software-driven re-engineering assumes the organization is similar to others in the field. Through the EHR software, the organization receives a set of configurable "best practices" that reflect the evolution of the vendor and software with the behavioral health marketplace.

As a practical matter, you've got to be a really large or really unique organization (unique in structure, funding streams, treatment plans, or payer requirements) to justify executing a purely organization-driven approach today. Experts say the strategy can be difficult and expensive. Monica Oss, CEO of Open Minds and another conference speaker, warned providers to avoid the temptation of "terminal uniqueness"--the sense that an EHR workflow must strictly replicate current office processes.

So, too, did Matt Dorman of Credible Behavioral Health Software, based in Bethesda, Md., who challenged the providers to recognize that "initial costs of customized software are just the beginning," and that the real costs may be "10 times the initial cost of the feature over time." Dorman adds that building in-house or customizing a vendor-provided EHR package also increases risks and costs associated with staffing. In the event of staff turnover, he says, "that 'must-have' feature may not seem so important anymore. You may find yourself asking, 'What was the reason for that feature? Why did we do that?'"

For reasons of speed and cost, and because behavioral health EHR vendors have continued to evolve their offerings over time, many behavioral health organizations have moved toward "software-driven re-engineering." They're adopting off-the-shelf EHRs that offer a growing degree of flexibility, with the ability to configure many basic features to local requirements. Given perennially tight budgets, this approach can help providers cut software development and maintenance costs, since upgrades come direct from the vendor. But it's still no easy task.

Peter Getts, controller of Hanover County, Va., Community Services Board and a recent implementer of EHR technology, explains that the flexibility and "configurability" of an off-the-shelf EHR package is important. The key is to be able to configure or modify details of the software to accommodate common process variables, management or performance reports, form fields, or payer requirements--without having to invest in the cost or risk of "customizing" software features.

Evans, a former clinician, explains one of the great surprises of EHR implementation-the fact that most process changes and transformations take place after implementation of an EHR: "How did we cope with process changes? Painfully," he recalls. "There was incredible resistance--especially with changing clinical processes--for the first six months. We spent all of this time clinically and direct service-wise to convert existing processes to electrons, but then we realized, 'Hey, we want to make some changes to make these processes better.' The lights went on."

Like Evans, most EHR users find that the process of implementation is where process changes begin, not where they end.


(1.) Mental Health Corporations of America, Inc. and Software and Technology Vendors' Association. Planning Your EHR System: Guidelines for Executive Management. Available at:

(2.) MHCA/SATVA whitepaper. Planning Your EHR System, p. 10.

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