I remember odd stories of people being referred to professionals and treated for conditions they didn’t have because they were mistaken to be somebody else with an entirely different problem. Wrong medications can be delivered or professionals can act under false assumptions when working with the consumer. Confusion like this can be avoided with positive identification methods available to the Electronic Health Record (EHR).
A little over a year ago, Rand Corporation said that the Unique Patient Identifier would cost $11 billion, and pay off nationwide in reducing these sorts of medical errors, and in simplifying the nationwide effectiveness of the Electronic Health Record (EHR), which in turn can introduce a high level of efficiency, and a way to enforce patient privacy. Thank you, Rand. In the EHR manufacturing world, we’ve been selling these ideas for many years. Hopefully Rand and other high-profile companies will help make the nationwide Unique Patient Identifier a reality.
One important result of the nationwide Unique Patient Identifier for consumers would be patient confidentially, or so we’ve said for over a decade. Patients deserve to have control over who knows their mental health diagnosis or any information about their stay in an addiction treatment center. Typically, we’ve accepted we will be identified by a number, so what number do we use? The Veteran’s Administration uses the social security number, identifying VA Hospital patients by last name and the last 4 digits of their SSAN. I don’t know if that’s good or bad, but it certainly seems effective.
Occasionally we hear of breaches in confidentiality like the loss of a Veteran’s Administration laptop in May of 2007 with a gazillion veteran’s names and numbers on it…like social security numbers. That single event woke me up to how important it is for me to maintain the confidentiality of that particular number.
Let’s use my old pal Kenny as an example of how this “secret” and private number has been spread around. Who has Kenny’s social security number? Oh, everybody, it seems.
In short, that secret number isn’t very secret, but it’s the closest thing that we have to an identifier. In my book, it’s time to abandon the idea of the social security number as a single identifier…it’s too compromised.
The solution for me seems to be technical. What’s done is done, and Kenny can’t do much about it. Perhaps you can. You don’t have to share your social security number with anybody…Verizon and the banks might argue about that, but it’s a law. These companies may not let you use their services and products as a result. No phone and no mortgage could be an inconvenience.
Signature pads have been in use for many years to validate consumer identity. A common software technology ties the signature to a patient ID. If consumer data needs to be shared with others, the patient signs for it, validating his Unique Patient Identifier. This assures the consumer is in control of who sees what. Without the signature, these entities who have your information can’t share it, and if they do, they are at great risk. Somebody could be open for a law suit or jail.
Voice technology, face identification, and retinal scans are a few other methods that can be used to validate Kenny is who he says he is, which is handy in the case of identity theft. Most of the organizations like credit bureaus and medical providers (probably your friendly neighborhood Community Mental Health Clinic) simply pair the SSAN with the date of birth, name and/or address, which is simple. Is that secure enough for you?
A solid, durable signature pad costs around $200 (the $100 model wears out quickly in a production environment and the $400 model with LED screens and interactive technology may be overkill). The other solutions cost a bit more, but so what? Technology is a pretty reasonable solution to assure nobody else is using a consumer’s ID, and confusing a person’s diagnoses and treatment with somebody else or spreading it across town or across the country without that person’s permission.
The simple point is, when it comes to treatment, maintaining confidentiality is tough and getting tougher as the National Health Record becomes a reality, and in the end, every citizen needs to take responsibility for the security of his ID. Keep your eyes and ears open, campers!
Read more →Years ago, while vice president of a small Electronic Health Record company, the dream of speaking into a microphone and having progress notes magically type themselves came up in every presentation, and the answer was similar to today’s answer: “That’s not part of the product, and it’s very possible using a product like Kurzweil Speech Recognition software”. We considered integrating speech recognition into our product.
Even back then, it worked great once you got it set up. The software needed to know your speech patterns, your voice and such. Any idiosyncrasies brought into the mix like dentistry or an injured tongue or a strong accent really threw the software for a loop. Like I said, the software worked fine, it was the setup and changing patterns of our voices that could throw a monkey wrench in the works. Consequently, speech recognition software was seldom used…Oh, I almost forgot, you could have bought our company for what the voice technology cost, so we declined to integrate the product.
The technology is much better now, and still in our field, seldom used. There are a number of high quality systems on the market that are available for a reasonable cost, like Dragon software, (and I imagine Kurzweil, too). You don’t have to go far for examples of how the technology has advanced. Most automated telephone systems with voice recognition do a good job, and the system that bowls me over is the Long Island Railroad system at 718-217-5477. Sometimes on a cell phone under less-than-optimal conditions, you might need to wait a while the system “thinks” about your response, but it picks up from that point well. Voice technology seems to no longer need much coaching or training to deliver what ‘s needed.
In mental health and substance abuse facilities, people ask about this technology for the benefit of those who don’t type. I learned to type in high school. I was a healthy boy and that’s where the girls were. I liked being there and over the years typing became a stream-of consciousness phenomenon. I don’t touch a writing implement often these days. My suggestion throughout the years has been to learn how to type if the effort and price tag is too high for voice technology. In this age of texting, select boxes, templates and drop-down dictionaries, that opinion has to go. The technology seems to have arrived, and by purchasing Voice Technology software for a PC, speaking notes and having them automatically type into memo fields us usually a snap.
Traditionally doctors have been the ones who used voice technology, historically that means Dictaphones. Today, it means software like those mentioned above. Most EHR software will accept input from the software. As I understand, the computer changes the voice input into typed characters, and they look like standard keyboard input to most software when your cursor is focused on a memo field.
It’s only rocket science, and we’ve been doing that since the Chinese invented fireworks rockets, long, long ago.
Once a doctor or other mental health professional uses the software, the text will still need to be edited, since we don’t write like we talk…not a big deal once we get the hang of using it, and that usually means the person using the software has to do the editing. This eliminates the drudgery and expense of having somebody listening to the recorded message and type the notes into the EHR.
Call me old-fashioned. I like to type. If you know professionals who don’t, suggest they look into voice technology; it’s a new world.
Read more →Change is good. All the folks I work with will experience big changes in 2011.
ARRA, the American Recovery and Reinvestment Act that has been a cornerstone of the Obama administration in pumping dollars into the economy will affect mental health and substance abuse treatment for both consumers and professionals in the upcoming year. $19 Billion has been set aside for Healthcare Technology and a good portion of that will be fed into organizations in the form of Medicare and Medicaid incentives for using the Electronic Health Record (EHR). Large agencies have been banking on this and buying EHR software in 2010, hoping that legislation that has been moving through the political system will pay either $44,000 or $63,750 for each doctor / prescriber using the EHR.
A number of healthcare providers are now in a race to implement the EHR and qualify for the big bucks. They will need to meet 15 core measures of performance with their EHR, so folks just now implementing software will need to hustle through the implementation and prove they meet specific functionality, or the money doesn’t come. They have until September to have all the 15 elements in place if they want to collect incentives in 2011.
ARRA is forcing significant change in the way professionals work and consumers receive treatment. Some professionals are struggling with central scheduling, having to turn over control of their schedules to somebody else in order to serve more consumers. Consumers who have been accustomed to being able to drop-in for treatment are being encouraged to make appointments, and sometimes need to wait longer to see a professional if they do drop-in to their friendly neighborhood community mental health center to discuss an emerging problem.
In 2011, more consumers will see treatment documentation first hand, some for the first time, becoming involved in developing their own treatment plan. The professionals and consumers are working together more and more often to organize their discussions into focused efforts to (1) address items in the treatment plan or include new problems in that plan to address (2) write the progress note to summarize the discussion from the perspective of both the professional and the consumer, and (3) plan next steps for treatment. The elements of this interaction are not new, however some professionals have kept them behind the scenes, and the transparency of the EHR is forcing them out into the open. Funding that includes documentation in the price of a session is forcing use of the EHR; documenting on paper is just too cumbersome and inhibits the effectiveness and speed of audits from Medicaid, accrediting bodies and internal quality control people.
But wait, there’s more change in 2011!
January 3rd, New York OASAS licensed substance abuse treatment organizations follow a number of other states in moving from “threshold billing” (one charge per day pays for all that day’s treatment), to “APG” billing (a fee charged for each service provided, under extremely complicated rules). This is a huge change for professionals and consumers. I work with an organization that plans to continue using a paper record and another that is committed to electronic treatment documentation. The major difference between the two methods is tracking the services for billing purposes. Connecting a billing record to the treatment documentation is easier to follow with the EHR. Both clinics have fine professionals treating the patients, and the consumers get what they need. The paper record is simply more of a hassle.
So, you see, the conspiracy to move to the EHR is in full swing. In 2011, some of the changes forced by the EHR may leave a bad taste in some mouths. On the other hand, it helps pay the bills.
Read more →A few years ago, I worked with a behavioral health hospital in Rhode Island to improve their Electronic Health Record (EHR), and the thing that impressed me the most was staff acceptance of carrying wireless laptops around the ward as they were treating consumers. They were constantly connected to the EHR, and this design not only encouraged, but enforced collaborative documentation of services with the consumers.
According to Ken Congdon, editor in chief of Healthcare Technology Online, there has been a resurgence of interest in this sort of technology, adapted to the iPad. Congdon speaks from a physical health perspective, and perhaps I can add to his research angled toward mental health and addiction treatment.
I approve of the iPad. PC guys like me and the Apple brigade have kidded each other about which is better, and a lot of us PC guys are starting to see real value in Apple’s products.
I’ve gone on the record many times as a supporter of collaborative documentation, and this technology makes that sort of treatment planning and documentation easer. The keyboard is as good as non-existent, so drop down dictionaries, checkboxes and radio (yes/no) buttons are pretty much a requirement for documentation. That speeds up the process while keeping the consumer involved…plus, who doesn’t like a gadget? Most consumers would at least be curious about the using the iPad. Imagine how easy it would be to assure a note addressed a treatment plan item by handing the iPad to the consumer and covering that first thing in a session. Then you’d have the bulk of your session (when the real work happens) without touching the little computer. After the discussion, the professional and consumer would summarize and record the next steps on the iPad, especially if the software has been creatively modified to suit this process. I think a number of consumers’ curiosity would help move this technology into the mainstream and improve the documentation, involvement and possibly treatment.
The Information Technology (IT) department or project manager for the agency’s EHR would need to turn attention to the way documentation is used, modifying some screens and better fitting them to work with the iPad. Since the trend is toward developing software to work in an Internet browser, tools that bridge the gap between the Microsoft and Apple technologies are already available.The project is certainly worth looking into.
Mental health professionals have been slow to adopt the EHR, and by tackling software design and implementation projects like this, the EHR’s acceptance by those same professionals might come along more quickly.
The technology does raise some concerns. Security needs to be a priority. Any time wireless technology is used, the passwords and firewalls need to be in tip-top shape. That’s not a problem, IT departments specialize in this, and if they need help, there are plenty of security experts and lots of security training in the world today as a result of hackers and virus attacks.
When a professional uses primarily data dictionaries, check boxes and radio buttons to complete an assessment, treatment plan or progress note, there is a very real danger of cookie-cutter documentation. For auditors, this approach to documentation is a hot-button and alerts them to review it very carefully with this regard. Again, this has been resolved by many software companies serving mental health and addictions (let me know if you want some suggestions for companies who have creative solutions). The note could be set up with a required “append” function that would alert professionals to add some narrative once they get back to their desk. Not a big deal, just an opportunity to be creative.
Once again, technology makes the world a more interesting, if not brighter, place.
Read more →It’s an old saying, “You don’t go to the hardware store for a loaf of bread!” When it comes to mental health and substance abuse treatment, it seems that’s what people are doing…and that complicates the business behind treatment.
I reviewed a presentation by Laurie Alexander, a peer in the behavioral health consulting world, and Karl Wilson of Crider Health Center, and was surprised to discover that when people seek mental health or substance abuse services, the first place they go is to their primary care provider. Upon consideration, I guess it makes sense, simply because we’re all connected, body, mind and spirit. Difficulty could enter the equation when the consumer may get a prescription without qualified, licensed counseling, and in this age of mergers and acquisitions and forging of business partnerships, that problem is being resolved.
Relating this to technology is not a reach. Mental and physical health software systems may have the same goal (to document health problems and solutions), however the way they work are tremendously different. At least one software program rooted in hospital-based, physical healthcare has tried to include feature-functionality for our sector. According to the customers I have met in my work, they had a tough time developing the software and never really got that part of the product off the ground, simply because they lack experience in the different way of documenting mental health and substance abuse services. The workflows are quite different for mental and physical health treatment.
Physical health software concentrates on a limited number of types solutions for health problems. Documentation tends to include electronic results from X-Ray, lab, MRI and other machines that are created automatically from the machine’s results. Other elements are fairly predictable, using a lot of check-boxes and very little narrative. Documentation of physical healthcare has grown into a pretty simple documentation solution for that Electronic Health Record (EHR).
Mental health /substance abuse software tends to focus on assessments that are developed in an agency and may or may not be suited to a bundle of check-boxes and drop-down elements for the sake of measuring outcomes. Treatment plans that consist of a series of problems, goals and objectives, and progress notes with a lot of narrative leave mental health and substance abuse treatment professionals forever writing. For decades software developers have tried to come up with a simple (EHR) that serves these needs, and have found that an important key to successfully implementing software is to suit the customer’s workflow patterns. This has been a trial. We are finding that staff transience among agencies and other factors are leading to a more homogeneous solution, seeing the same software features in many of the mental health/ substance abuse treatment EHRs on the market
Once I went to the CEO of a software company I worked for with an idea to include physical health documentation in the mental health software. He’d spent over 25 years building software specific to our sector. He chuckled at the idea saying, “We can’t even spell what they want to track!” In other words, it wasn’t the software’s core competency and including physical health features, while possible, was not advisable simply because the company didn’t have the rich experience in physical healthcare—it was a different world to us.
It’s true that physical health and mental health oriented software can both generally handle each other’s business, and the difficulty in crossing those lines is that the manufacturers just don’t have the widespread experience in all areas of their business to readily handle both worlds…yet. That experience is being gained now.
Because ½ of all mental health and substance abuse services are performed by physical health clinics, and because the trend in mental health is to have physical health professionals on staff, software is evolving, and companies in both business sectors are coming to know the other side of the coin. Electronic Health Records (EHRs) are getting better, including more functionality that’s sensitive to workflows both in physical health and mental health/substance abuse treatment.
Read more →When you visit your friendly neighborhood Community Mental Health Center, the gap between adaptation of the Electronic Health Record (EHR) in general healthcare and the behavioral / addiction treatment world becomes evident pretty quickly, especially if a consumer is filling out paper forms in the lobby with a worn-down pencil with no practically no eraser left.
It’s getting better.
Recently, in helping a large New York City agency select an EHR, I was surprised to hear they had no common Master Patient Index (MPI). That’s a program that can relate the EHR to other software, like the Human Resources system. The goal of that sort of internal interoperability is keeping the same demographic data common among all the software systems in an agency.
Small and mid-sized agencies end up having to pay software vendors extra to connect their programs, foregoing an MPI mostly because of the added expense. Few saw that this could blossom into a continuous pain, so internal interoperability, sharing of data among an agency’s software programs, takes a back seat to paying the electric bill or giving holiday bonuses (hallowed ground, the holiday bonus).
Most physical health hospitals spent a lot of time and money over the past few decades concentrating on the MPI because they don’t want their doctors and nurses to spend their high-priced time re-writing a consumer’s name, address and other demographic information. Mental health and addictions treatment is just catching up, but we still find licensed professionals and front line staff re-writing this information…oh, and don’t forget about that consumer in the lobby with the worn down pencil. That little metal thing that holds the eraser onto the pencil has just torn through the form for the eighth time…he could get frustrated any moment, and he just wants help with his mental health problem. Perhaps an MPI would help expedite his treatment
Most of the larger agencies bought software for programs piecemeal. First, the accounting department got their software, then the automated time-clock appeared, which by rights should share professionals’ information with the human resources software…you get the picture. The result was a plethora of disconnected software, and it’s not difficult to see how we got to the point of needing the MPI, but not knowing much about it.
If you have three software programs feeding into a central MPI, the MPI must be king of the data, so it can send updates to the consumer’s record out to all those other programs. Sounds simple, but it’s not. Vendors of MPIs charge a pretty penny for their software and support with good reason…brokering changes to a consumer’s health information is serious business, and you gotta get it right, every time.
The agency I mentioned earlier (with no MPI) grew into the need over time, adding different sorts of programs to help them serve people with developmental disabilities and mental health disorders. Not-for-profit agencies’ business priorities seem to have a history of underestimating the value of all those minutes that can be saved when staff, professionals and consumers don’t have to fill out their name and address with that worn down pencil over and over again…not to mention the great benefit of cutting down on graphite and rubber (eraser) pollution.
Like I said, it’s getting better. At least we know what an MPI is, and are learning the value of it in this age of mergers and acquisitions.
Read more →Because I am expected by my current healthcare provider, I spend less time in the waiting room and no time filling out forms. That’s a far cry from my experience with other healthcare professionals. In times past, an appointment didn’t matter; I was destined to wait, and was always filling out forms with the same information.
My current healthcare provider delivers physical and mental health treatment, everything except dentistry, and for every appointment, I receive a couple reminders, and that’s an effective perk for a forgetful guy like me. First, there’s a printed reminder in the mail. It’s a very clear letter that simply states the date, time and place for the appointment, and who I’m meeting. It’s a wonderful thing to have all this attention paid to me and my poor memory. Incidentally, I record the appointment both in Outlook on my desktop and synchronize that to my BlackBerry. A day or two prior to my appointment, I get a telephone reminder. I’m fond of reminders, and apparently a lot of folks appreciate them; a few years ago, a study at the University of Rochester in New York showed over 75% of those polled thought they were a good idea.
I go with the flow, and make my appointments. It’s easy for me to assume these sorts of systems work. The letter can be generated by many scheduling systems that are built into the EHR, and a number of automated telephone-reminder systems are available to integrate into the scheduling system. I searched the internet and immediately came up with an option that looks like it would work from Stauffer Technologies in Cleveland. If I was in the market, I’d check it out further.
The letter is generated by the computer as part of EHR, most EHR reporting systems will tap the database to send out form letters. The telephone calls are generated by the computer interfacing the EHR to an automatic system with a computer generated message. I am simply not a “No-Show” because of this attention, and since these reminders are automated, nobody needs to write or print a letter, and nobody has to call me. These technical solutions contribute to the bottom line and can help assure that struggling mental health clinics will be around to help consumers as the business continues to change.
In Community Mental Health Centers, No-Shows account for tremendous revenue losses simply because they leave professionals sitting around doing nothing, or perpetuating the myth that they need that time to catch up on their paperwork. In August, I quoted a study commissioned by the National Council (the mental health community’s most popular support organization). One of the agencies in the study showed a professional had a couple No-Shows a month and canceled another couple to “catch up on paperwork” (see my past posts discussing collaborative documentation for another solution).
I can’t help but think that the possibility of No Shows is decreased for more folks than me by the use of letters and telephone calls generated by the EHR…they certainly get me into the office.
Read more →I have a beef with every doctor’s office I’ve ever been to except one. It’s those forms I have to fill out and papers I have to bring when I come in for an appointment. They have all the information in (or available to) their computers, yet they insist on wasting ink…and I wonder how they can read my handwriting these days anyway.
There is no point to it or reason for it. My health information could be printed out for a quick review easily enough, or just left on the screen. If the professional treating me wants to know the results of an excursion to another sort of healthcare provider, that information’s available electronically, too.
Health Information Exchange (HIE) has been around a long time, and these organizations specialize in security of our health information while sharing it among professionals treating us. Information on my address, health conditions, or prescription for a psychotropic drug is nobody’s business except professionals who treat me, and I really want that information shared securely to those folks. Since treatment is so disparate, it’s good to know that the physical health doctors, hospitals and mental health and addiction treatment facilities we use can access a medication list, or a discharge summary from other providers.
I believe our body, mind and spirit are all connected, and if I’m unconscious or incapacitated when brought in for treatment, people treating my body may need to know what’s been going on with treatment for my mind…I’d rather not be subjected to a bad drug-to-drug interaction or mis-diagnosis of a symptom. HIEs go a long way toward eliminating possible problems like these, simply by sharing personal health information among professionals.
It’s a bonus that the HIE can share my address and phone number so I don’t have to write it down on that silly form. Still, I see that only at the VA because it’s a monstrous healthcare system that has concentrated on the Electronic Health Record (EHR) for decades, and my data is available coast to coast, only to professionals who I want to see it.
A lot of care providers simply don’t belong to the exchanges and aren’t about to turn lose of the monthly fee to pay for that sort of security and efficiency…they’d rather send a fax when sharing health information. Investing a few moments investigating could put dollars back into the professional’s pocket. InformationWeek shared that Dr Mark Sandcock’s primary care practice in South Bend, Indiana saved $1 Million in the first year of working with an HIE. So, his patients benefited, and presumably, so did his family with holiday gift giving.
Lab results can drag out treatment simply because the information takes a while to travel between healthcare organizations and get processed…outpatient addiction treatment facilities have learned that getting urine toxicology results quickly when testing for abused substances helps confront the consumer quickly, which aids treatment. The paperwork and people involved in getting the information between the healthcare facility and the lab and re-recording results in patient charts, also adds to the cost of healthcare, and that affects the price tag when we go for help. Experiences like Dr Sandcock’s give me hope that the healthcare system may actually be coming around to better serve consumers and prices may actually stabilize.
HIEs are growing, and the string of positive outcomes is impressive, from prompting better healthcare decisions because folks who treat us being able to see our medication history to quick receipt of lab data. One factor really stands out for me: soon, I won’t have to fill out those silly forms when I go to an appointment, even if I’ve never seen the professional before.
Read more →America recently swapped out a number of Democrats for Republicans with the promise to voters of decreased government spending. As a result, a number of mental health and addiction treatment facilities could face increased hardship. Their primary source of paying the rent is drying up…Medicaid funding looks to be continuing a downhill slide.
Once again, mental health and addictions facilities are faced with improving the way we do business and securing alternate revenue sources. Every time this challenge has arisen over the past couple decades we’ve overcome it by improving the way we do business. I’m particularly grateful about this because it’s allowed me to make a living helping these folks become more efficient and effective by using the Electronic Health Record (EHR)
I tend to agree with Chuck Ingoglia, Vice President of Public Policy for the National Council for Behavioral Healthcare (NCCBH), when he forecasts that Medicaid funding in our business is likely to decrease over the next few years.
So, as Medicaid dollars shrink, the agencies need to make up for that somewhere, and as the old story goes, it’s better to teach somebody how to fish than simply give them their next meal.
One way to make up for losses in funding is to sharpen up with better use of the EHR. A number of mental health and addictions treatment providers are trying to make better use of their software by encouraging use of central management of practitioner scheduling in order to make sure their workload increases. As that workload increases, collaborative documentation, writing the notes and developing treatment plans as part of a therapy session becomes more a part of daily business. Just using the EHR this way leads to shorter wait times for a consumer to see a professional for the treatment they need, and helps focus on the problems in the treatment plan rather than digressing into the crisis of the moment with no direction toward recovery.
Facilities taking care of business with creative measures like this will survive, and some of them will flourish.
Recent gains made in healthcare reform will face some losses, and popular mandates like mental health parity that assures insurance companies must pay mental health and addictions claims on par with physical health claims will likely stick around. Consumers who benefit from reform measures are more easily motivated to write their legislators and encourage them to support reform gains.
For the past couple years, a number of mental health and addiction treatment facilities have been successfully weathering business changes required by decreases in their funding. A small rehab in Wisconsin survived long enough with a grant in order to implement enough of the EHR to assure they collected payments (or at least partial payments) from self pay consumers…sometimes that’s as simple as asking for a payment at the time of service. Before the EHR, they simply had no working system to do that. A mental health provider in the Midwest lost their grant funding and started reaching out to gain new self-pay and insurance consumers. They instituted sliding fees where they were warranted, and tracked accounts for this new way of doing business with their EHR. They aren’t flourishing, but they’re still helping people as a result of these marketing and business changes.
These are examples of a fighting spirit. These are people willing to make significant changes and a few sacrifices in order to continue helping others recover from mental health and addictions problems. Lately I’ve been helping a couple agencies switch from one method of funding to another, and in the process, helping them make better use of the EHR. Ten years ago, staff would have groused and fought the change. Now, I’m met with growing enthusiasm. You know you’re making headway in the battle to succeed when the troops lead the way into change.
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