Self-creating an EHR system

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.

Paramount to the project's success was selecting a software package that would provide for ease of development and continued growth. As mentioned, Lotus Notes was selected as the software for developing the system, because it is largely a workgroup package that promotes organizational collaboration in product design and finished application use. Given the collaborative team approach C4 chose for system development, Lotus Notes was ideal. The ability to embed electronic signatures within any Lotus Notes documents, for example, was an inherent feature of the software that was deemed crucial, since the agency wanted to maintain all records online and eliminate printing of documents. Lotus Notes also exceeded all regulatory encryption requirements, ensuring that highly confidential client data would remain secure in the agency's online, multilocation environment.

An additional Lotus Notes feature crucial to the project's success was its discussion boards. This bulletin board system was most frequently used as applications were introduced throughout the organization. All clinicians were encouraged to post their comments, concerns, questions, and suggested improvements regarding any application they were asked to use. This direct end-user feedback was invaluable in identifying improvements that only enhanced both the system's utility and user buy-in.

Training staff

From the start of the project, C4 took the approach that all of its staff would achieve success using the system and that no one would be left behind during the rollout. During the first years of implementation, training was provided in a computer classroom at the agency's central office. Specifically, a training room was created with 15 workstations where users followed instructions visible to them from the instructor's data entry via an overhead projector. Once these initial trainings were conducted, clinical managers agreed as a group that they could train their staff independently on any additional applications, similar to the way that they had trained staff on new manual documents. This approach was successful. In fact, three years into the project's implementation the computer classroom was dismantled for lack of need.

One particular problem recognized at the start of the project was that many staff had limited keyboarding experience. The agency purchased licenses of the Mavis Beacon keyboarding software for any staff who requested a copy. Also, upon request, one-on-one training from a Computer Help Technician was made available for anyone who felt as though they needed personalized help.

“JAWS for Windows,” a screen-reading software, was interfaced with Lotus Notes to allow the agency's visually impaired staff to use the system as fully as others. It was also helpful that many managers had been among the group of staff with limited computer backgrounds, as they could share their experiences of having to learn something new with staff under their supervision.

The system in action

Within a year of deciding to develop its own system, C4 had implemented the essential features allowing for transmission of its claims to its funding sources. It would take about three more years until all major system components were in place. The EHR was designed to capture data as soon as a client contacted the agency, initiating the opening of the Intake Fact Sheet for client registration. The client was then scheduled for an assessment through the Centralized Scheduler. Once the assessment was complete, the online Treatment Plan was completed authorizing the delivery of care documented through Service Notes. An e-prescription system is also part of the overall EHR.

Although there are exceptions to this data flow for situations such as emergency cases, the general movement of client data through C4's EHR is illustrated in figure 1.

Figure 1. Information flow through C4 EHR applications.

The timeline for implementing the applications (figure 2) shows that the agency did not introduce modules to staff in the most logical order, and it highlights lessons learned from this experience. Although the agency needed to ensure that its Service Notes database was implemented as quickly as possible to make sure that potential Y2K issues were addressed, the assessment module would ideally have been implemented even earlier; there would have been definite integration benefits to having it in place before the treatment plan module. Similarly, it would have been more efficient to concentrate on physicians' e-prescription needs by including this essential stakeholder group in the process sooner, as well as have access to vital medication data earlier. Similarly, there would have been definite advantages to including the Centralized Scheduler earlier in the order of introduction, as it seemed counterintuitive to staff to implement this following introduction of the Service Notes.

Figure 2. Timeline of EHR activities.

Results

Since its initial implementation, C4's outcomes have been very positive. Billing revenues grew substantially, claims rejection rates diminished to insignificant levels, clinical practices improved through the automated advancements, and internal user satisfaction exceeded expectations. The administrative and support resources previously required for data entry, charting compliance reviews, and accounts receivable maintenance all dropped by 75 percent. Audits of the agency have had excellent results. For example, all state Medicaid audits have found the agency to exceed 99 percent of the standards measured.

Also, C4's clinical management has consistently reported high degrees of satisfaction, because the agency now experiences: 1) a higher level of service delivery and quality of care; 2) a decrease in the time spent documenting services; 3) quicker and more thorough review of client progress toward meeting clinical goals; 4) higher reliability in identifying and addressing clinical needs; and 5) greater integration in treating health, financial, and social issues in connection with behavioral issues.

Once it had neared its goal of fully implementing a complete EHR, C4 strived to further improve its organizational efficiency and end-user satisfaction through additional technological advancements. C4 is focusing on those growing demands common to most providers: regulatory compliance, utilization review and optimized productivity, while simultaneously creating an environment that is encouraging, supportive, and appreciative of quality care.

C4's program now includes a host of automated compliance solutions, including a liability alerting/quality improvement system that provides clinicians and their managers with real-time prompts and summaries regarding treatment shortfalls, contradictions in care, and charting irregularities. Similarly, an online closing audit program was developed that scans the entire record and forces deficiencies to be addressed prior to staff submitting the case to the clinical records department for closing. It also includes an electronic utilization review system that provides reviewers with the ability to efficiently analyze all necessary components of the case from a single form that summarizes the client's care, and then links the reviewer to parts of the record necessary for review. Moreover, a performance management system provides immediate and customized daily, weekly, monthly, and yearly measurements necessary to most efficiently monitor and manage performance.

The implementation of C4's more recent approaches continue to have significant impacts for the organization. “The implementation of the automated compliance components has helped the agency tremendously to ensure that it successfully meets all funding and regulatory requirements,” says Victoria Ruder, C4's compliance officer. “C4 now has much stronger assurances that the claims that it submits will stand up to the most strenuous audit measures. Beyond being so much easier to complete now, UR is done in a much more systematic way that staff feel to be a worthwhile process rather than one that is to be avoided.”

Similarly, Bruce Seitzer, C4's Chief Clinical Officer, explains how the performance management initiatives have improved the organization's operations: “We feel very fortunate to have automated our clinical record and the immediate efficiencies and benefits that have been the result. To go beyond that tremendous goal and to have figured out how to best utilize our data for management decisions with the end-user in mind makes us appreciate even more our work in developing the system. It makes a big difference to clinicians that they know the system will support them in getting their work done correctly and on time through the weekly deadline reminders and other quality improvement alerts. They appreciate the refinement of a system that allows them to focus on providing direct care instead of having to invest time and energy in keeping track of seemingly endless regulatory requirements. Likewise, managers have a strong grasp on how their areas are functioning, on which staff need focused support or training, and the outcomes that have occurred. It definitely feels like we are all moving in the same direction and share common understanding of our goals by both the organization and the clients we serve.”

All in all, C4 built a package of unique and innovative applications that serve as a model for organizations to adopt once they have implemented an online clinical records system.

Community Counseling Centers of Chicago (C4), a behavioral health and social service provider, offers quality, comprehensive services tailored to the cultural and economic diversity of its consumers. Since 1972, C4 has dedicated itself to providing counseling experience and expertise to heal and help men, women, and children of diverse racial, ethnic, and economic backgrounds who are struggling with mental illness, substance addiction, emotional trauma, and the aftermath of violence. Since its inception, C4 has continually developed services particularly directed to persons in poverty, addressing a multitude of behavioral health and prominent social problems in the community, including specialized services for victims of sexual assault. C4 served 7,447 registered clients in Fiscal Year 2008, providing approximately 250,000 unique services. C4's diverse clientele consists of 37% African-American, 29% Hispanic, 27% White, 3% bi-racial; 2% Asian, 1.5% “other” and 0.5% Native American. Fifty-three percent are male and 47% female. Ninety-seven percent live below the poverty line and 50% have no income. Sixty-three percent live with family or significant others; 18% live alone; 10% live in supportive housing, such as nursing homes, halfway houses, jails, etc.; 7% are homeless; and the domiciles of 2% are unknown. Within the past 12 months, C4's services have reached more than 9,000 low-income men, women, and children. C4 has an operating budget of approximately $16 million.

C4 received the National Council for Community Behavioral Healthcare 2009 Award of Excellence in the Use of Technology for its EHR development. In 2004, C4 received the J.J. Negley President's Award for Excellence in Risk Management.

Paul Stieber, MA, MBA, is the Chief Information Officer (CIO) for the Community Counseling Centers of Chicago (C4). Before pursuing administrative positions in behavioral healthcare, Stieber was an inpatient psychiatric counselor for six years with Parkview Memorial Hospital of Fort Wayne, Indiana, and worked in the outpatient area as an ACT case manager for Park Center, Inc., also of Fort Wayne. For further information, call (773) 765-0770, e-mail paul.stieber@c4chicago.org, or visit https://www.c4chicago.org. Behavioral Healthcare 2010 January;30(1):26-29