During the past two weeks, I have spent several hours creating process diagrams or flow charts for a customer. After using our billing software and a custom attendance/reporting module we created for them in 2003 but maintaining paper clinical records, they are now implementing a custom Forms module and preparing to implement our behavioral health electronic medical record (EMR) product.
Clearly, understanding their current work flow is essential to assure that the steps we follow to implement the electronic record will cause minimal disruption of their productivity and maintain their confidence in their billing and cash flow. The goal of the CEO and CFO is to seamlessly provide and document services so payment audits do not result in lowered funding; the goal of the clinical staff is to help addicted people recover from their addictions and become productive citizens; and the goal of the billing staff is to assure that services are accurately reported and billed so the agency is paid for services provided.
The end point we plan to reach is that billing will not occur until documentation of the treatment is in place, but getting to this point will be a gradual process. Helping clinical and business office staff understand the job responsibilities, work flow and the anxieties of their colleagues will allow them to work more effectively as part of a team. The team, of course, shares the goals of providing the best clinical services as efficiently as possible and assuring that payment is obtained for those services so they all can continue doing their respective jobs.
While this flow charting was a time-consuming process, it was most instructive. One thing we have learned in almost 25 years in business is that our customers rarely use our products in the way we designed them. . . .and each organization does things differently. This customer was no exception. For us to make assumptions about how the counselors and business specialists in this or any of our customer organizations do their work would be foolish, at best.
A couple of months ago, our business development manager indicated that she gets frequent questions from prospective users wondering how they will integrate an EMR into their current work flow. Should they enter the progress note into the program while the consumer is in their office? If they wait until the client leaves, won’t it take too much time? Trish suggested that we write a blog article on how clinicians utilize our EMR in the course of their work. We decided to ask a couple of our customers to describe their work process so we could get a more accurate idea of how they work.
The answers to our inquiry were very interesting, and different from one another. As could be expected, the work flow of a psychiatrist/psychopharmacologist and that of a psychologist/psychotherapist were quite different. We are grateful to Scott P. Hoopes, M.D. of Meridian, ID and Scott Gale, Ed.D. of Franklin, TN for their input.
We were interested to find that neither Dr. Hoopes nor Dr. Gale enter a progress note while the patient is in the room; that happens after the patient has left. We also learned that neither provider relies upon a staff assistant to enter clinical information; they are both comfortable with a keyboard and prefer typing their own note to the more involved process of dictating, reviewing and correcting transcription, copying the note to the patient file and signing it. Dr. Hoopes does manage prescriptions while the patient is present, including reviewing, creating and sending the prescription to the pharmacy.
We learned that Dr. Gale, in spite of his use of our electronic clinical record since 1992, still scribbles notes and thoughts on paper while the patient is in his office. He scans these notes into electronic storage and shreds the paper. (As a solo provider without support staff, he does everything in his practice.) While he could attach these scanned documents to the patient’s file in the EMR, it is my impression that he considers this brief process note to be his work product. . .the psychotherapy note that HIPAA allows a psychotherapist to keep and store separately and not to release to an insurer. His note in the EMR is the formal record of the service provided. While some recommend against maintaining a separate set of psychotherapy notes, we have found that many of our customers do so. For some, this is the main reason not to move to an EMR. . .they are not sure how they would continue to maintain these psychotherapy notes while also using an electronic record.
Dr. Hoopes’ work flow was developed after time working in a community mental health setting where he was expected to see five patients in an hour. In 1995, not very long after starting his private practice and struggling for a while with paper records, he started using our software for billing, electronic claims filing and clinical records. Eventually, he also added scheduling.
His current work flow allows him to see his schedule at all times. Prior to the arrival of his patient, he brings their record onto the screen and makes a quick review. He duplicates the last progress note into one with today’s date for editing after the patient leaves. In the fifteen minutes he spends with each patient for a medication check, he is able to be engaged with them to determine their progress or lack thereof. Based on the information obtained, he decides to continue or alter their current medication, making any needed adjustments and sending the prescriptions to the pharmacy. He walks the patient out to the receptionist, who electronically schedules their next appointment. He returns to his desk, edits the progress note with today’s status, signs the note, and calls up the record of the next scheduled patient, repeating the process between 20 and 32 times a day.
My guess is that other users of our EMR product and of other products in the marketplace follow both very similar and very different work processes in their organizations. After all, while most of our customers provide behavioral health services, each is different, with varying clinical and business cultures. In every case, to most effectively implement a behavioral health EMR, it is essential to have a clear picture of your pre-EMR work flow and your goal for use of an EMR. Both of these will make it easier to choose and to implement the EMR of your choice.
Please share your experiences with the work flow in your business. Is work flow analysis something you have ever done? If so, what was your motivation? We would also love for you to share your work process experiences with implementing an EMR, if you have done so. What changes were necessary in your work flow to fully utilize the EMR? How successful have you been in that process?
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Seth Krieger says:
I recently tried dictating into Case Manager using Windows 7’s built-in voice interface. Although it accepted the dictation, the text did not paste into the text field when I was done, as it should have. I tested several other programs and found that it worked in some, but not others. This might be a case of “you get what you pay for” and Dragon might work fine. I just don’t know.
A couple of years ago, however, we modified Case Manager to make it tablet-friendly. That is tested and works well, especially in Vista and Windows 7. I would argue that adjusting to a handwriting interface is much easier than to a voice interface. In addition, you can use handwriting even when you are in a noisy environment that makes dictation impossible.
Kathy says:
Spence, I really like the idea of entering the progress note with the client present and sometimes even having them enter the note. Finding a way to make that work smoothly can be done as part of planning the work flow and training staff.
Kathy says:
Paula, currently, Dr. Hoopes faxes prescriptions using Case Manager. We are looking at e-prescribing software options for the new future. You should be able to use Dragon Naturally Speaking with the software, at least in the memo fields. We have not tested it, but they claim you can train it to work with any software.
Paula says:
I am curious what program the MD uses to send prescriptions, you can’t do that through case manager can you? After looking at case manager, it seems quite time consuming to type or enter an eval. Any thoughts about connecting or syncing dragonspeak as an option with SOS?
Spencer Gear says:
Interesting blog, Kathy. Our goal in life is to have the therapist do the note as an integral part of the session with the client. This means changing a lot of things – for example, can the client see the screen? (You would hope so, because you want them to see what you say, so you might need a second screen). Is your scheduler blocking off other clients’ names? How are you working your actual therapy process – towards the end of the session saying something to the effect of “Well, let’s see what we have said here….did I get the key things?” What actually should go into the note? (Many therapists write too little; others too much). And on and on……… There is some research that suggests that clients don’t object to this, and in fact often prefer this approach because “I can finally see what you say about me!” and because it gives them an opportunity to recap and correct the record.