CONCURRENT DOCUMENTATION WINS TRIFECTA

Abstract

The result is far fewer human errors, far fewer rejected claims, and far more efficient trearments. Because of the intensive involvement of front-line nursing and clinical staff with clients and client documentation, they were a logical choice to receive the first structured forms developed by Wilkerson's team and the first group whose work with the new process would be measured.

Headnote

How one documentation project made clinicians, clienps, and even accountants happy

Mental Health Centers of Central Illinois (MHCCI), an affiliate of Memorial Healrli System (Springfield, 111.) is a private, not-for-profit provider of behavioral health and rehabilitation services, serving some 10,000 individuals from multiple locations in six counties that include the cities of Springfield, Lincoln, and Jacksonville.

A longtime user of electronic billing and an early adopter of electronic client records, MHCCI continues to invest in health information technology applications. Since 1 989, when its first billing system went live, it has evolved a sequence of products offered by The Echo Group (North Conway, N.H.), most recendy into the Clinician's Desktop/EHR package.

Burdensome, costly paperwork

In early 2009, MHCCI undertook an agency-wide operations review in response to plunging national and state budgets for behavioral health services. A few months later, tn May, the agency's director of quality management and outcome evaluation, Jim Wilkerson, was asked to join with staff to address a major issue from the review: the growing burden and cost of state-mandated paperwork required for reimbursement of care to publicly funded behavioral health patients.

"Due to financial conditions in Illinois, we were looking at ways to increase revenue, decrease staff stress, and decrease paperwork load. Our staff told us that they had a lot of paperwork to do, something that we well knew, and it became a big discussion," Wilkerson recalls. "That's when we came across this concept of concurrent documentation (CDoc) and we thought, 'Ah, that's a good idea, to work the same way that medical doctors do, charting die entire time [with the patient]. Can we figure out a way to make this happen?'"

"How can we make everything work together?"

With initial concurrent document training and strategic direction from MTM Services (Holly Springs, N.C.), Wilkerson and his team started the project by understanding the time expended by staff on clinical documentation. At the time, he recalls, "We were really in the middle of implementing the EMR," noting that the team was actively working on plans to convert important, paper-based clinical documents (client assessments, treatment plans, progress notes, and more) into easy-to-use electronic forms. Immediately, he explains, "We started thinking: 'How do we do stuff?', 'How does the EMR do stuff?', and 'How can we make everything work together?'"

Within that thinking was an important realization: The EMR could help, but it wasn't a silver bullet. "Everyone knows that if you bring up an EMR, that doesn't mean less paperwork," says Wilkerson. "Less paper, but not less 'paperwork.' So we were looking for ways to reduce the time that staff spent documenting." A pilot study found that, for every one-hour appointment, clinicians typically would spend 1 1 minutes documenting afterward. "When you add that up, that's a whole lot of time spent documenting, instead of with clients," says Wilkerson.

More documentation, but less typing

So, the challenge was not only to "convert" paper-based documents to electronic form, but to rethink and redesign them based on the requirement that they reduce the overall workload and that they be displayed, completed, and stored in the context of a 'live' treatment appointment. To accomplish this, the team decided to use "structured" electronic documents.

Compared to typical paper documents, such as progress notes, where a question may be followed by a blank answer box (for writing or typing), Wilkerson says that "a structured progress note lays out a variety of things - fields, boxes, check-offs, numbers - then flows you through them to ensure that you complete them." The object is to simplify and speed up the documentation process by recording the maximum amount of information, consistently and repeatedly, with the minimum amount of typing.

While the movement of hand across paper makes it easy to cram a lot of information onto a few multipurpose paper documents, Wilkerson's team found that reducing paperwork electronically would require more, not fewer, forms. They created a series of structured forms, each geared to specific tasks and particular users. "Theoretically, you could use one [structured form for all], but the key is to make it efficient for each person who's using it - that's why there are multiple progress note forms." (See figures IA, IB, 2A, and 2B.)

Following "the golden thread"

Through logic capable of locating and associating thousands of diagnoses, diagnostic codes, treatment requirements, related treatment codes, and coundess otiier bits or bytes of information, EHRs help providers coordinate activity efficiently around what consultant MTM Services calls "che golden thread" of treatment.

The golden thread begins with che pacienc assessment (identified needs), then pulls through the treatment plan (interven dons and goals) to ongoing progress notes (patient efforts, services provided, progress made). And, it is golden because, if accurately followed through, the documentation that supports each decision, intervention, or patient progress noce contribures co a complete record of pacienc care, error-free and ready for reimbursement.

Documentation speed jumps 360 percent

Compared co paper-based systems that depend on human memory, process, and judgment for completion of required elemencs of care chat underlie specific diagnostic or billing codes, EHRs work behind che scenes, managing and presenting each client's information based on the role performed by defined system users. Starting with client intake information and an initial diagnosis, for example, MHCCI's EHR system helps pull the golden chread: ensuring a march between billing codes and work.

"The EHR links the billing to the discussion associated with it," says Wilkerson. The result is far fewer human errors, far fewer rejected claims, and far more efficient trearments.

Because of the intensive involvement of front-line nursing and clinical staff with clients and client documentation, they were a logical choice to receive the first structured forms developed by Wilkerson's team and the first group whose work with the new process would be measured. Three quarterly measurements show, to date, that documentation time among these professionals fell, on average, from 11 minutes per session to just three minutes - -a 360 percent improvement. According to Wilkerson, much of the improvement happened quickly, within the first quarter after the process change. He notes chat documentation time, while down, does flucruate based on the mix of forms that clinicians must complete during the quarter.

A surprise for clinicians

Wilkerson explains that, during its introduction, che concurrenc documencation approach required clinical staff to interact with cheir cliencs in a new way. Clinicians would make noces during the course of an appointment, while a computer display screen enabled clients to observe (figure 3). When this change was piloted, it proved unsettling for some. "My biggest surprise with all of this was the initial resistance by some staff members to have clients read what was said about them.That piece threw me for a loop initially," Wilkerson recalls.

But he could see where the clinicians were coming from. "It was a new process, and if a client disagreed with what the clinician typed in, a discussion had to occur. The differing points of view had to be brought together."

Ultimately, it took time to develop consensus about how best to introduce the process to clinicians and clients alike. Wilkerson sums up the discussion like this: "The key to concurrent documentation is being able to document the information with the client. Most clinicians complete notes at the end of a session, summarizing what was discussed and learned, what the patient will be working on. So, we say to the clinician, 'You're going to do [the notes] as you learned, but now, you're going to enter them in the computer at die same time that you give them to the patient.' So, when the clinician is ready, he or she might say to the patient, 'Lets go over here and draft our progress note, our summary, together.'"

Common ground with clients

"There are," he continues, "a lot of positives that come out of that." In addition to the comfort of clinicians being able to finish work sooner, Wilkerson says, "I often hear from staff members that they had one clinical impression, but that the client was ¿hiking differently. Sharing [during the summary note process] helped to drive a different understanding, a common ground of understanding for the therapist and the patient."

Clients have also had their say, says Wilkerson. "We've heard a lot of feedback that clients feel more involved - the process definitely supports a recovery-focused approach," he notes. Quarterly surveys of client satisfaction/clinician engagement show a strong positive response.

Going on the road

Recently, the concurrent documentation effort has gone mobile, enabling staff to document the provision of services outside the office. Once again, the process was kicked off with a presentation by MTM Services, highlighting the fundamentals of conducting offsite or mobile meetings, inviting client participation in the progress notes, transmitting client information securely, and managing mobile information technology.

"Now," says Wilkerson, "we can meet with clients and do concurrent documentation anywhere, provided that [the location] is HIPAA appropriate."

Presently, the team is continuing development of structured forms to be used by MHCCI's doctors. Their concerns are unique, says Wilkerson, because "in addition to doing a progress note on an individual, which is what everyone else has to do, the docs have to update a diagnosis on every set, update labs on every set, and update meds on every set." He says chac che ceam is "looking closely" at the process for ways to make it easier and faster to use, to "ensure that che docs aren't just typing everything in."

Material, process, and staff savings

"We're noe complecely paperless, bur we are working cowards ic. It's a long journey," says Wilkerson, who took a moment to explain the value of "going paperless."

While chere are "obvious savings, like paper, chac you don'c have co buy," Wilkerson says chat eliminaring "the movement of paper" in the office offers the kind of savings that accountants really notice. "If something is printed, you pay for a staff member to get up, pick up that piece of paper, sign it, and run it through whatever submission or management process you have. Then, when that's over, you pay someone to file it." Reducing the movement, and inevitable loss, of paper records means that MHCCI was able to free administrative staff for other responsibilities in the office or for transfers elsewhere in the health system. "We didn't let anyone go, but we have reduced expenses," he says.

Just as important, the switch to concurrent documentation has reduced stress. "One of our staff members said it was 'a life-changing event,'" Wilkerson recalls. "She explained that since progress notes are due at 10 a.m. the next day, if she was unable to finish her progress notes before leaving che office, she would worry abouc starting che next day behind, having to catch up." Now, he adds, "we encourage people to 'work your work schedule and go home.' It shows that, as an agency, we recognize there's more to life."