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Clinical Workflow: Assessing What Your Organization Wants and Needs

Mercer Government Human Services Consulting. TABLE OF CONTENTS . Step 1: Introductions and Purpose of the Session 3Step 2: What does your county organization do? 8Step 3: Advantages of Electronic Medical Record13Step 4: Clinical Functions Available in the Marketplace19Step 5: Implem

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Clinical Workflow: Assessing What Your Organization Wants and Needs

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    1. Clinical Workflow: Assessing What Your Organization Wants and Needs May 2003

    2. Mercer Government Human Services Consulting TABLE OF CONTENTS Step 1: Introductions and Purpose of the Session 3 Step 2: What does your county organization do? 8 Step 3: Advantages of Electronic Medical Record 13 Step 4: Clinical Functions Available in the Marketplace 19 Step 5: Implementation Strategies 57

    3. Mercer Government Human Services Consulting

    4. Mercer Government Human Services Consulting Diane Vrenios is a consultant with Mercer’s Government Human Services Consulting Information Technology Group. She assists public organizations with implementation of information technology and has worked with California counties. Prior to joining Mercer, Diane managed information technology for the State of Arizona behavioral health services agency. Kathy Sternbach is a consultant with Mercer’s Government Human Services Behavioral Health Consulting Group. She has worked with several California counties on their behavioral health systems of care. Her clinical training is in psychiatric rehabilitation and she directed public mental health programs at the local, state, and national levels.

    5. Mercer Government Human Services Consulting Purpose of the Clinical Workflow Session: Strategies to Identify What Your County Needs Part I: Interactive Presentation (1.5 hours) Review key clinical functions of direct care and managed care organizations Discuss advantages of electronic medical record Identify key clinical software functions Understand pros and cons of available technology, including web based applications Assess what will work for your organization Consider implementation options Break 5-10 minutes Our goal today is to help you identify strategies for determining what IT clinical functionality your County needs. In our experience, when an organization decides to implement new information technology, it is not uncommon to look for “all the bells and whistles”. Sometimes, the technology out there looks so impressive, that you can end up with a fancy system that that majority of staff do not use. For example, how many people here have had to use new a new electronic gadget? a phone – a VCR – a DVD player? How many people, when you get the new device, read thoroughly the full instructions manual, walk through all the functions, and use 90% of the capabilities of the gadget? These people are usually in the minority. And, how many turn it on, figure out how to get the basics working, and then move on, referring to the manual when they get stuck, or better yet, asking another user how to do something..… We hope by the end of the session, you will be thinking of specific strategies to identify the critical IT clinical functionality your County needs. Review each agenda item… Our goal today is to help you identify strategies for determining what IT clinical functionality your County needs. In our experience, when an organization decides to implement new information technology, it is not uncommon to look for “all the bells and whistles”. Sometimes, the technology out there looks so impressive, that you can end up with a fancy system that that majority of staff do not use. For example, how many people here have had to use new a new electronic gadget? a phone – a VCR – a DVD player? How many people, when you get the new device, read thoroughly the full instructions manual, walk through all the functions, and use 90% of the capabilities of the gadget? These people are usually in the minority. And, how many turn it on, figure out how to get the basics working, and then move on, referring to the manual when they get stuck, or better yet, asking another user how to do something..… We hope by the end of the session, you will be thinking of specific strategies to identify the critical IT clinical functionality your County needs. Review each agenda item…

    6. Mercer Government Human Services Consulting Purpose and Format Part II: Working Session (1.5 hours) Develop strategies for your county to: Identify priority clinical functions Plan implementation approach discuss your individual county’s current use of electronic medical record, assessment tools, and outcome tracking strategies to help your county determine its software

    7. Mercer Government Human Services Consulting Acknowledgements The computer screen slides in this presentation were prepared by Dale Jarvis CPA, MCPP Healthcare Consulting using material from the following software vendors: Allscripts Healthcare Solutions Askesis Development Group Anasazi Software CMHC Systems Creative Socio-Medics The Echo Group Group Health Cooperative Physician Micro Systems Raintree Systems Mr. Jarvis provided invaluable assistance for this presentation based on his work with Clinical Focus Groups in preparation for today’s session.

    8. Mercer Government Human Services Consulting What does your county organization do? First, we are going to take a look at the broad brush question – what is the primary focus of your organization?First, we are going to take a look at the broad brush question – what is the primary focus of your organization?

    9. Mercer Government Human Services Consulting Clinical Functions: What does your county organization do? Provide direct care services Manage care Combination The type of clinical functions that your County will need, depends, in part, on whether you are the main provider of services, or whether you have an extensive provider network that you manage as a managed care organization (MCO). If you are primarily a direct care organization (DCO), your information planning requirements will be focused on direct care. If you are a managed care organization, you will need more “bells and whistles” if you have a large provider network. Ask: “How many counties provide direct care and MCO functions?” “ Which of your counties are small, medium, large?” “Rural or urban?” The type of clinical functions that your County will need, depends, in part, on whether you are the main provider of services, or whether you have an extensive provider network that you manage as a managed care organization (MCO). If you are primarily a direct care organization (DCO), your information planning requirements will be focused on direct care. If you are a managed care organization, you will need more “bells and whistles” if you have a large provider network. Ask: “How many counties provide direct care and MCO functions?” “ Which of your counties are small, medium, large?” “Rural or urban?”

    10. Mercer Government Human Services Consulting Direct Care Organization (DCO) - Key Functions Assessment Alerts for high risk cases – suicide/medical needs Treatment plans Progress notes Medication Order entry Outcome tracking Best practices Integration with claims system If you are a provider of services, your primarily focus will be on systems that support care delivery – eligibility - electronic record – linkage to automated billing – insurance tracking In today’s session, we will be focusing on the information technology needs of the County as a direct care/provider organization. However, we will highlight some of the differences in information planning needs between direct care organizations and MCOs, because many Counties are both direct care organizations and MCOs. If you are a provider of services, your primarily focus will be on systems that support care delivery – eligibility - electronic record – linkage to automated billing – insurance tracking In today’s session, we will be focusing on the information technology needs of the County as a direct care/provider organization. However, we will highlight some of the differences in information planning needs between direct care organizations and MCOs, because many Counties are both direct care organizations and MCOs.

    11. Mercer Government Human Services Consulting Managed Care Organization (MCO) - Key Functions Care authorization/utilization management: Treatment plan Type of service and authorized units of service Tracking authorized units and reauthorization Alerts for high risk cases – suicide/medical needs Track cases by episode Mechanism to discharge/close cases Provider network data base for referrals that selects by: age and gender language/culture clinical specialty geography Tracking grievance and appeals Provider profiling capacity Reporting/quality management Integration with claims system With the MCO function, the focus is on eligibility determination, referral to a network provider, and care authorization and utilization management, reporting, and claims management. The IT system emphasizes managing the network of providers who deliver care to consumers. We want to emphasize the differences between managed care organizations and direct care organizations, because the IT functions are different for MCOs and we have found some confusion in terms. For example, some direct care organizations think of the term “managed care” as contracting with insurers or MCO vendors who authorize care. In this situation, the provider needs information technology that tracks service authorization from the insurer and “flags” when it is necessary to request additional sessions or treatment. If you are a MCO, then you must provide a way to track care you have authorized, flags to note session limits, and reauthorization functions. With the MCO function, the focus is on eligibility determination, referral to a network provider, and care authorization and utilization management, reporting, and claims management. The IT system emphasizes managing the network of providers who deliver care to consumers. We want to emphasize the differences between managed care organizations and direct care organizations, because the IT functions are different for MCOs and we have found some confusion in terms. For example, some direct care organizations think of the term “managed care” as contracting with insurers or MCO vendors who authorize care. In this situation, the provider needs information technology that tracks service authorization from the insurer and “flags” when it is necessary to request additional sessions or treatment. If you are a MCO, then you must provide a way to track care you have authorized, flags to note session limits, and reauthorization functions.

    12. Mercer Government Human Services Consulting Combination – MCO and Direct Care Provider Dual function: Provide direct care services Manage a provider network Today’s session focus: Information planning for the county as a Direct Care Provider We assume many Counties provide direct care services, as well as, managing a provider network. The size and scope of the provider network is a key factor in assessing whether your County needs MCO functionality. Today, we are focusing on information technology for the County as “direct care provider”. Another session is focusing on information technology for MCO functions.We assume many Counties provide direct care services, as well as, managing a provider network. The size and scope of the provider network is a key factor in assessing whether your County needs MCO functionality. Today, we are focusing on information technology for the County as “direct care provider”. Another session is focusing on information technology for MCO functions.

    13. Mercer Government Human Services Consulting Advantages of Electronic Medical Record

    14. Mercer Government Human Services Consulting Advantages of Electronic Medical Record (EMR) Provides immediate access to consumer’s information for clinicians who need it: Medications Crisis plans Physical health issues Other information during emergencies Links treatment plan to progress note, promoting: Continuity of clinical focus Improved documentation of rehabilitative or active treatment interventions (Medi-Cal, Medicare, Medi-Medis) Limits access to medical record to clinicians and supervisors involved with the case. Discuss slide Focus on improved documentation capacity – the software can be programmed to help you meet documentation requirements of different and conflicting payers, for example, meeting rehabilitative requirements for Medi-Cal and active treatment for Medicare. Diane will give an example about access to medical records.Discuss slide Focus on improved documentation capacity – the software can be programmed to help you meet documentation requirements of different and conflicting payers, for example, meeting rehabilitative requirements for Medi-Cal and active treatment for Medicare. Diane will give an example about access to medical records.

    15. Mercer Government Human Services Consulting Advantages of EMR (continued) “Flags” key activities: High risk case reviews Medication reviews Routine reviews Insurance authorization Quality initiatives Automates billing once progress note is complete. Increases legibility: Important for record users Useful to obtain reimbursement New generation of hand held devices aid in data entry and retrieval. Self – explanatory – Emphasize the capacity to link completion of the progress note to billingSelf – explanatory – Emphasize the capacity to link completion of the progress note to billing

    16. Mercer Government Human Services Consulting Sample Feature of an EMR

    17. Mercer Government Human Services Consulting Challenges of Using EMR Culture shift - transitioning from paper to computer screen Typing skills of users Confidentiality concerns related to computers Resistance to change Time for training Emphasis on office-based technology Use of new hand held devices Data entry if clinicians don’t use electronic record directly Front end preparation to link clinical and billing requirements

    18. Mercer Government Human Services Consulting In Summary, the EMR…

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    20. Mercer Government Human Services Consulting Assessment Clinical Assessment: Presenting problem Mental status Diagnosis Medication Risks related to physical health or mental status Periodic and ongoing assessments

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    27. Mercer Government Human Services Consulting Treatment Planning Software features: Standard templates with options for modification Generates a goal or problem list Access to a “library” of potential interventions that fit the goal or problem Flags for service reviews and discharge planning Provides medication information

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    29. Mercer Government Human Services Consulting Sample Treatment Planning Steps

    30. Mercer Government Human Services Consulting Treatment Plan

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    33. Mercer Government Human Services Consulting Progress Notes Software provides options and tools: Blank template the clinician completes Standardized templates with drop-down boxes Lists of providers and services Prompts to help the clinician meet documentation requirements “Incident to” Active treatment Rehabilitation

    34. Mercer Government Human Services Consulting Progress Notes – Sample Screen Notice this sample screen links the treatment plan to the progress note, which is very useful to report on progress, particularly when reporting on treatment for Medicare covered consumers.Notice this sample screen links the treatment plan to the progress note, which is very useful to report on progress, particularly when reporting on treatment for Medicare covered consumers.

    35. Mercer Government Human Services Consulting Progress Notes: Documentation Prompts for Medical Necessity (Medicare) Treatment is appropriate for the condition Treatment meets reasonable standard of care Intervention must require skill of a licensed practitioner Condition is amenable to favorable modification or If goal is stabilization, there is evidence of deterioration prior to onset of treatment Treatment is at most cost effective level

    36. Mercer Government Human Services Consulting

    37. Mercer Government Human Services Consulting This tool assists the clinician to conduct service reviews and/or write discharge summaries by highlighting treatment items that need to be resolved. This tool assists the clinician to conduct service reviews and/or write discharge summaries by highlighting treatment items that need to be resolved.

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    39. Mercer Government Human Services Consulting Medication & Drug Formulary Management Medication management software: Identifies appropriate medications and links to best prescriber practices. Tracks usage and dosage. Enables reports for quality management purposes. Formulary management: Provides database of medications on and off formulary. Identifies whether prior authorization is necessary. Displays a list of drugs most commonly prescribed for the ICD-9 diagnosis of the consumers. Some software may combine these functions.

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    43. Mercer Government Human Services Consulting Order Entry Physicians/RN orders entered electronically: Prescription appears at the pharmacy unit. Lab work requests goes to the laboratory. Referrals are easily tracked. Process: Clinician orders a medication or service electronically. Consumer returns to receptionist who has access to the order screen or print out and schedules the appropriate follow-up activity. Consumer goes to pharmacy or lab to get the prescription of lab test. Receptionist schedules appointments with other clinicians.

    44. Mercer Government Human Services Consulting Outcome Tracking Check if the vendor can accommodate other software packages that focus on outcome tracking, especially ones that may be mandated for your county. Ask which “outcomes” software the vendor has integrated with their system. Identify the cost and timeline for enhancements as well as vendor staff to help with TA after purchase and implementation. Be prepared for fragmentation: Vendor may be able to address some integration, but not all. Standards for measuring outcomes not yet fully tested. Picking one set of outcome measures now will not necessarily address your future needs, especially as outcome definitions and measurement standards become more scientifically based . We understand that different counties are using various software packages to track outcomes, some of which are mandated. Discuss with participants which outcome software they are using, if any. We understand that different counties are using various software packages to track outcomes, some of which are mandated. Discuss with participants which outcome software they are using, if any.

    45. Mercer Government Human Services Consulting Best Practices Some software packages link to best practices, e.g., medication management for the diagnostic code. Ask about the vendor’s approach to incorporating “best practices” in their software. Is it scientifically based as determined by an outside body, e.g., JCAHO, national research center, etc.? Assess whether you need access to the advertised “best practice”. Is this a feature you can use now or phase in later? Will your clinicians use the feature?

    46. Mercer Government Human Services Consulting Access to Clinical Information Verify that software vendors meet all HIPAA and other federal requirements pertaining to privacy ad security. Ask if software will have security clearances built in. Security clearances will be assigned based on involvement with the consumer. Access to appropriate parties based on “need to know”. e.g., Clinical teams will have access to clinical data. Billing teams will have access to the data sets necessary to process bills.

    47. Mercer Government Human Services Consulting Clinical Form Development Software “forms”: Ask whether you can incorporate your forms into the software. But be careful not to develop multiple iterations of the same form, e.g., treatment plan. Standardized forms are best. Drop down boxes and text can address different needs. Base your forms on the “clinical workflow” – how a consumer enters and moves through the system. Use of EMR will require some paper forms, e.g., forms for consumer signatures and maintenance of a paper record for these forms. The various software vendors will have different forms for treatment plans, assessments, progress notes, etc. Check on what type of flexibility you will have to amend forms. You may be able to incorporate some of the existing forms and formats your County currently uses. However, make sure to assess what’s available and compare this with your existing forms – you may be able to update your forms and improve information flow by using the vendor’s format. The EMR is not completely paperless. You will have to have a paper file for forms that require a consumer’s signature and maintain these as part of the clinical record. The various software vendors will have different forms for treatment plans, assessments, progress notes, etc. Check on what type of flexibility you will have to amend forms. You may be able to incorporate some of the existing forms and formats your County currently uses. However, make sure to assess what’s available and compare this with your existing forms – you may be able to update your forms and improve information flow by using the vendor’s format. The EMR is not completely paperless. You will have to have a paper file for forms that require a consumer’s signature and maintain these as part of the clinical record.

    48. Mercer Government Human Services Consulting Ease of Use for Clinicians Software should be able to do the following tasks: Can print all case notes in a readable, user friendly format. Can flag high risk cases, co-occurring disorders (or selected disorders, based on outcome focus of the county). Can access a limited number of fields if the clinician has to update information, e.g. telephone number of address change. Can access websites, such as www.webMD.com to quickly pull up a subject and print educational information for the consumer.

    49. Mercer Government Human Services Consulting Ease of Use for Clinicians, continued User friendly software? Visual image Software logically follows consumer flow? Balance of typing and point and clicking? Access to computers? Each clinician? Central workstations? Ergonomic issues: Proper equipment set-up Effective lighting Aids to minimize disability – wrist pads, etc.

    50. Mercer Government Human Services Consulting Special System Needs of Consumers and Clinicians: Additional Features Consumers: Ability to print appointment reminders for consumers Medication information and reminders Access to web-based “self-help” information Clinicians Ability to schedule non-client appointments on the scheduler Ability to track and report on CQI indicators Capacity to access historical consumer information

    51. Mercer Government Human Services Consulting Hardware – Tools for Clinicians Hardware Desktop PCs Hand held devices PDAs Notepads / pens Tablet PCs Laptops Voice activation

    52. Mercer Government Human Services Consulting Web-based Systems Vendors may use the phrases: web-enabled web-based web-supported web-access … in a variety of different ways. Systems that are accessed via the internet browser Systems that allow connectivity to the internet (links) Systems that utilize the internet for communications Internet, intranets, extranets (Do we really need all these nets?)

    53. Mercer Government Human Services Consulting Latest Technical “Tools” – Tablet PCs

    54. Mercer Government Human Services Consulting Implementation Strategies

    55. Mercer Government Human Services Consulting Who’s On First? Critical linkage: Clinicians must be involved from the beginning: identifying software needs championing the software to make sure clinical issues are addressed linking with billing staff to set up the right “billing codes” jointly deciding policies and procedures with billing office and IT specialist designing forms helping with implementation strategies Clinicians must determine the consumer’s diagnosis, not billing staff. Clinicians must select the billing codes based on the clinical service rendered. Coding can be a computer function only after the clinicians and billing staff meet to identify appropriate codes Coding can be a computer function only after the clinicians and billing staff meet to identify appropriate codes

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    57. Mercer Government Human Services Consulting Implementation Approaches (continued) Approach C: 1st: Assessments 2nd: add Treatment Planning and Progress Notes 3rd: add Service Reviews and Discharge Planning (Rationale: start with steps that match the consumer’s clinical entry to the system. ) Approach C is our recommended approach because it follows the consumer in the process. Assessment forms the basis of treatment planning. Progress notes should reflect the consumer’s status in relation to the treatment plan.

    58. Mercer Government Human Services Consulting Part II: Working Session Develop strategies for your county to: Identify priority clinical functions. Plan implementation approach: Discuss your individual county’s current use of electronic medical record, assessment tools, and outcome tracking Strategies to help your county determine its software Discussion…

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