Technology that informs treatment

Not many years ago, Texas state officials found that addiction treatment provider organizations’ clinical care documentation was dangerously inconsistent and incomplete. According to state records, 42 of 63 patient charts evaluated in a 1999 random review included no evidence of a diagnosis or listed a diagnosis inconsistent with the client's level of care or length of stay.

Less than a decade later, the Web-based electronic health record system that guides both clinical treatment and billing for the state's addiction treatment providers stands as a model both within Texas and nationally. This turnaround, driven originally by a state agency that hardly had been considered a model of efficiency at the time, occurred through a carefully phased process of automation that tried never to lose sight of users’ needs.

As a result, the Texas Department of State Health Services’ Behavioral Health Integrated Provider System (BHIPS) received a 2006 Nicholas E. Davies Award of Excellence in the Public Health category. The Healthcare Information and Management Systems Society (HIMSS) awards the annual honors for innovative uses of information technology in healthcare.

The description of BHIPS's functionality required a full three pages in DSHS's 17-page application for the Davies Award. The Web-based system governs all clinical, financial, and quality improvement functions for the addiction services provider organizations under contract with the state to provide publicly financed care. The state department's deputy commissioner considers the system's comprehensiveness an essential element to BHIPS's success.

“A critical juncture occurred with the decision to connect the electronic record to the billing system,” says DSHS's Dave Wanser, PhD. “It was important to connect doing the work to getting paid.”

Program's History

The development of BHIPS parallels a larger effort to transform health and human services state agencies to improve efficiency—an effort marked by the consolidation of 12 state agencies into 4 departments. One of those four is the Department of State Health Services, created through a merger of the state's public health, mental health, and substance abuse agencies.

The latter of those three former agencies, the Texas Commission on Alcohol and Drug Abuse (TCADA), had been under a great deal of scrutiny in the 1990s over its program and spending accountability. At the time, agency officials had begun to discuss ways in which to ensure better continuity of care in publicly funded addiction services. The agency's clinical director took an idea that started as an online case management system and asked, “Why not do the whole clinical record and do it in a Web-based system?” recalls Dr. Wanser, who was at TCADA at the time.

TCADA remained committed to several important concepts during early development of the electronic record, knowing that it would need to obtain provider organizations’ buy-in for the effort to succeed. “We were committed to the concept of ‘no redundancy,’” says Dr. Wanser. “We never wanted to have a situation where a clinician had to enter something in more than once.”

Also, knowing that clinicians might balk at having to enter in so much more client data than they had been used to recording, state officials kept their focus on making sure the data collection efforts were tied to improving practice, Dr. Wanser says. Today, that plays out in provider organizations’ ability to generate dozens of reports from the system to inform their quality improvement initiatives. It also helps that the state's contracted substance abuse providers have begun reporting on a consistent set of outcome and performance measures, making it possible to conduct valid comparisons between organizations.

BHIPS's features run the gamut from online progress notes to discharge reports to a waiting-list screen to automated reminder messages for clinicians. But Dr. Wanser considers the system's assessment tools among the most critical elements for broadening the vision of treatment and guiding treatment planning. BHIPS includes a sound mental health assessment that has allowed addiction clinicians to offer a more integrated behavioral healthcare plan.

“We’re raising the standards of practice, and saying that treatment of co-occurring disorders is a part of what we do,” Dr. Wanser says.

In addition, as issues are identified in the assessment, BHIPS automatically records them as part of the treatment plan. This has forced clinicians to think about their services on an entirely different level, incorporating issues such as trauma, homelessness, and family violence into their efforts to help clients make progress, Dr. Wanser says.

But these requirements for provider organizations in using the system were not introduced all at once. The entire process was phased, with the online assessment introduced first. State officials put the assessment piece up on the system and then monitored its use. Once about 30% of its funded provider organizations were assessing clients using the electronic tool, the state required use of the online assessment and then moved on to treatment planning in the same fashion, and so on.

In addition, the state established several mechanisms for ongoing provider feedback. It created an online chat room where system users can help one another. It staffed a telephone help desk for provider organizations, manned first by IT professionals but later by program staff when it was determined that this role was not an efficient use of IT experts’ time, Dr. Wanser explains.

The state used a combination of federal and state monies to build BHIPS. According to DSHS's application for the Davies Award, about 85% of spending on BHIPS came from federal block grant funds, with state general funds accounting for the rest.

Overcoming Clinician Concerns

For clinicians who had been accustomed to working in a paper-based system and documenting their efforts sporadically, it was important that they not perceive the new automated clinical record as difficult to navigate. In addition, state officials had to overcome clinician concerns related to how BHIPS would affect their one-on-one relationship with clients.

Clinicians at the outset especially were concerned that their need to record clinical notes while clients were present would make clients feel uncomfortable. “The biggest concern we heard was from clinicians who didn’t want to use the computer while the patient was in the room,” Dr. Wanser recalls. The state and providers discovered, however, that when the clinician and the client worked together on an online version of the Addiction Severity Index, for example, the process helped engage the client.

“When you sit with a client and put something in the computer, the client makes sure you get it right,” Dr. Wanser says.

Strict controls over how client information is shared in the system also have soothed providers’ confidentiality-related concerns.

Over the years, the state has added numerous features to BHIPS based on new areas of emphasis in the state-funded behavioral health system. For example, when the state received a federal Access to Recovery grant to offer treatment and recovery support services to clients in the criminal justice system, it created an online voucher for the innovative payment method through which clients obtain services under Access to Recovery. Also, BHIPS is used to manage diversion programs within the Texas Department of Criminal Justice and as part of the NorthSTAR managed behavioral healthcare program in a seven-county area surrounding Dallas.

A Provider's Perspective

One of the pilot users of BHIPS was Homeward Bound, a provider organization that operates residential and outpatient addiction treatment services in Dallas and a small detox facility and outpatient program in El Paso. Executive Director Doug Denton says the state's Web-based system certainly eased the paper-to-electronic transition for his organization, noting that he didn’t have to invest in buying a software system.

Denton says providers who use BHIPS no longer have to guess about what is causing certain challenges in their organization. If it is seeing an increase in the number of client discharges against medical advice (AMA), the system can pinpoint common elements in where the departing clients are coming from and what they are experiencing.

“I can give out an up-to-the-minute report on almost any statistic you can think of,” Denton says.

BHIPS also has proven beneficial to Homeward Bound in helping make its grant applications more information-based. The organization is about to embark on a research project for the opiate addiction medication buprenorphine that is supported by the National Institute on Drug Abuse's Clinical Trials Network. Denton says it would be difficult for the organization to qualify for such projects without the access to the detailed client data that BHIPS affords.

Denton's only reservation about BHIPS is that he believes his busy clinicians never should be asked to report on data simply for reporting's sake. Provider organizations should be required to measure only what can be used to improve quality in an organization, he says. “I don’t want clinicians spending time providing data that are not relevant to services,” Denton adds.

Looking Ahead

Joe Vesowate, DSHS's assistant commissioner for mental health and substance abuse services, says state officials continue to build on BHIPS's capabilities, always focused on basing the next step on an analysis of what has been done before.

State officials say they never considered any option but developing the system in-house, because no product on the market would have fulfilled their diverse and ambitious goals. Also, “If we didn’t own the source code, it was going to cost more money than it needed to,” Dr. Wanser says.

BHIPS is serving as a model both within Texas and nationally. DSHS officials believe their efforts to integrate behavioral health services through this electronic tool could serve as the precursor to establishing an electronic record for all state health services in Texas, Vesowate says.

In addition, BHIPS already served as the impetus for the Substance Abuse and Mental Health Services Administration's Web Integrated Treatment System (WITS), a project designed to assist states interested in using shared technology for treatment. Five states and one urban county are using WITS for their substance abuse service systems.
Dave Wanser, PhD

Sidebar

2007 Davies Awards

HIMSS is accepting applications for the 2007 Davies Awards. The Davies Awards, established in 1994, are for excellence in the implementation of an electronic health record system, and they are intended to encourage such efforts throughout the healthcare field. The awards are given each year to one or more deserving organizations in general healthcare, and for the past six years the awards also have been made available to deserving organizations in the behavioral healthcare field.

For information on applying, visit https://www.himss.org/davies. Brief, preliminary threshold applications are due in March (see Web site for specific dates). Questions can be directed to David Collins, MHA, manager of the HIMSS Davies Award Program, at (703) 837-9817 or dcollins@himss.org. For behavioral health-specific questions, contact Tom Trabin, PhD, one of the behavioral health representatives on the Davies Award Committee, at (510) 236-6868.