Anne Paschall

Ohio Department of Mental Health

1. ODMH’s long term goal is a complete electronic medical record for its inpatient and outpatient programs that is web-enabled and can provide information electronically to all of its payers and even the patients/clients.

2. We already have an electronic system for our inpatient population that keeps historically diagnoses, allergies, medication orders (which begin with physicians ordering and orders being passed immediately to the nurses and pharmacists for validation/confirmation and passed onto the automated drug machines for medication distribution), history of medication taken, cancelled, etc., laboratory results, seclusion and restraint episodes, unusual incidents, medication errors, adverse drug events, treatment plans and clinical services integrated into our system. This system also does all of the EDI billing for the inpatient population and ORYX reporting for JCAHO. This system is not web-enabled even though it is real time. We have prototyped a web interface with the computerized physician order part of the system and have a proposal to implement this interface and expand it to other areas. The treatment plan is a package that we try to integrate with the rest of the system, and the company is phasing it out, so we have to replace that part of the system in the next 14 months.

We also have an outpatient system that registered our clients, tracks services, does the billing electronically and electronically processes the returning 835 for account receivable. However, this is a packaged system that we do not like that is also being phased out by the vendor, so we will have to replace it sometime in the next year. It is a GUI system but not web-enabled.

4. Lessons learned:

a. There must be strong clinical, management and IT leadership or the system(s) will not ever be implemented. There must be a Clinical and Administrative Sponsor who must believe in this project.

b. You must have a strategic plan that prioritizes your competing electronic system needs, and you must use a strong project management approach. There needs to be a group of your top administration who manages this process and reviews at least monthly.

c. Unless the data is used for operational/clinical support or billing, the data will not be accurate or useful. Data can only be collected once or it will not match. The admission, discharge, transfer and movement data must feed the clinical and the billing systems at the same time. The medication systems have to be linked from the computerized physician order entry all the way to the automated distribution machines and even the e-Medication Administration Record. The data should not be collected or even stored in more than one file except for data warehouse/analysis purposes. The data should be shared for the different applications if it is going to be accurate data. Do not enter medications and/or lab results manually. There must be an electronic interface with labs (using HL7), and the drugs cannot be entered manually unless they are the physician entering the order as part of his ordering process or the pharmacist entering the order as part of the ordering process. Both the physician and pharmacist should not enter the same order. The pharmacist should only review orders entered by the physicians.

d. The clinicians must receive added value from the clinical systems or they must be paid if they are going to enter any of the data. This added value can be medication related ordering alerts, alerts to orders expiring or other workload issues, paper reduction because of elimination of redundancy, convergence of lab results with the ordering process, etc. They do not see better administration/management as an added value.

e. Treatment plans, progress notes, scheduling, service documentation and billing must be integrated to be useful and accurate.

f. There must be one view for each professional type that is relevant to their work flow/process, and there must be an easy way to access the system. You cannot have multiple signons or have signon processes that are too elaborate or lengthy or staff will not use the system.

g. The systems should tie into the e-mail systems and any other collaboration system that your organization may have.

h. You should use HL7 standards to pass clinical data electronically and work to have these standards hardened.

i. At least 20% of any organization will resist the change no matter how well you plan for the change process.

j. Not all suggestions/ideas are equally valid. You must have a way to legitimately evaluate these competing suggestions/ideas and to communicate the change control process throughout your organization. There are only so many changes that any organization can absorb at anyone time.

k. Don’t underestimate the computer phobia that many people have. Much of the clinical staff in our organization is older and did not grow up with PCs or the mouse interface. Training the basics must be done repeatedly and continuously because of turnover. Training on each application must also be done continuously, and there must be good training material preferably on-line. However, once there is one well established clinical system, it becomes easier to install new applications or modules.

l. Make sure you put in a strong/reliable infrastructure and that you have backup procedures (some even manual) in place or the system will fail.

m. Have a friendly and competent help desk that can make suggestions for systems improvement. Make sure there is a local group that can train and field questions as well.

n. Establish a change control process starting with each location that feeds into a central organization and interfaces with the group in a. This group can also sponsor users groups, IT summits and brown bags. They can help identify super users hopefully in every unit on every shift. Also, establish a communications matrix for communicating changes and any outages.

4. We have mostly shared information internally except for reimbursement and with a laboratory company which are covered by HIPAA so we haven’t had to worry about some of this. We do have the County Mental Health Boards wanting more data than we are legally allowed to share at the moment so we don’t share clinical data. However, when we are transferring a patient to a community agency, and we only share if the patient has approved the sharing which meets HIPAA requirements. As the payor, the Boards can actually view their patients on-line but only their patients and only the information that is applicable to the payer. The agencies cannot view on-line. They receive a computer generated report, but we would like to send it electronically using an HL7 interface, but they are not ready to receive this type of communication yet.

Mental Health data is more sensitive than regular health data so all of us are concerned about confidentiality and security. We have tried to build strong firewalls around our data, and we are unaware of any breaches to date. However, we have not made the system accessible through the Internet yet (just Intranet) because we are still reviewing our security. It would be nice for doctors to be able to access from the Internet, but we have prohibited because of inappropriate access concerns. We use SecureID for the Board access, outpatient access and some technical access. This control seems to work pretty well and may be expanded.

We consider our inpatient (9 sites) and outpatient care (23 programs) to be one system of care so we are allowed to share data between these programs. However, we do not allow a site/program to change another site’s/program’s data. Also different types of people are permitted different views of the data based on their need to know.

Prime sponsors, users groups, change control managers, project managers and Help Desk staff are all critical facilitators that you will need.

5. We would be willing to have our data included anonymously in aggregate data. We would not be willing to provide patient identifying data. We would want to be able to refuse the sharing of our information until we understood the benefits of sharing.