As large healthcare organizations across the country transitioned into electronic record management, often with HIPAA (The Health Insurance Portability & Accountability Act of 1996) regulation deadlines as a powerful catalyst, many behavioral healthcare and addiction treatment facilities and practices continued to rely on paper files. Until recently, off-the-shelf electronic systems weren't designed for relevant customization for these applications.

If you are still operating solely on paper, it's time for another look at electronic alternatives. Now retail electronic record management systems can offer a number of benefits to behavioral healthcare and addiction treatment facilities, particularly small to mid-sized organizations and private practices. Secure, easy data input and access should top the list of requirements. Being able to utilize professional looking clinical record printouts, and even to clearly read them, audit records quickly and standardize charts and information - are all benefits. And there are tangible opportunities to enhance quality of care with a hybrid or electronic system.

The processes to ensure safety and security concerns are streamlined with electronic record management. Access to screens is matched to an employee's job function and need-to-know. The HIPAA Privacy and Security Rules have been specific, and require standardization of electronic administrative procedures and data interchange, protection of confidentiality and security of health data through setting and enforcing standards.

The HIPAA Privacy Rule requires that patients authorize permission to share records with other medical/healthcare providers outside the immediate healthcare practice, and healthcare organizations must have safeguards to prevent unauthorized access to records. Electronic data management comes with the potential for more accurate, secure and timely client record keeping.

For accreditation purposes, record management practices and systems also become more accurate and streamlined with electronic record keeping. While meeting federal and state regulatory and accreditation standards can be managed efficiently with electronic systems, the bonus to many clinicians is that electronic systems have proven to be an effective clinical tool throughout the continuum of care.

In the past, the record keeping function was primarily only for documentation purposes. Electronic systems and the resultant real time documentation now enable clinicians to use record keeping for clinical treatment planning.

Investing in an electronic system may be costly initially, but consider the long-term cost savings. Eliminating overlap of procedures and other significant time savings impact the bottom line.

The customized approach: Hazelden's RMIS

Any record management system for a behavioral healthcare or addiction treatment practice must have a core focus on access, quality, control, safety and security. For a large, multidisciplinary treatment facility like the Hazelden Foundation, the proprietary, custom designed Recovery Management Information System (RMIS) manages record keeping systemically for the five key clinical functions: pre-entry, intake, assessment, treatment care and continuing care planning, as well as discharge. New retail systems can address these functions, too.

The RMIS system is also utilized by non-clinical functions such as marketing and research. The results for every department and the efficacy of the record management function itself have prompted Sally Brandenburg, director of health Information and Quality Standards, and Hazelden veteran of 34 years to say she couldn't imagine record management without RMIS.
"The RMIS system supports the focus on quality and safety of client care, and security issues," said Brandenburg. "Financial case management records are managed accurately. Clinicians have ready access to pertinent information for assessment and treatment planning, supervisors can review data for quality improvement and information is easily located and identified because system formats are standardized."

Prior to 1998, a hybrid paper/electronic system was backed up by microfilm. It was expensive to maintain, and relied on a single paper record file per patient. In hard copy systems, clinical team members often couldn't access the file in order to input or document client notes, record input quickly or access it simultaneously. Filing clinical notes was often perceived as a task, not a clinical tool, and records were kept in a locked file. It was sometimes difficult to know where a file was at any given time. And sifting through a stack of charts three inches thick could be time consuming at best.

In the mid 1990s, planning for the RMIS system began. It was designed for installation in stages, with maintenance by the internal IT team and members of treatment and quality departments. While paper is still important with the critical nature or timing of medication orders and administration, these functions will also be addressed electronically in the future.
It is no coincidence that Hazelden's clinicians buy into the RMIS system. Two of the team designers are themselves clinicians with technical knowledge, Janelle Wesloh, director of RMIS and Privacy Operations, and Sam Dresser, manager of Business Application Projects. Designed from a clinical viewpoint, the system's cross-functional applications were designed with the input and buy-in of the clinical staff and other department supervisors and stakeholders, including financial case management, human resources, alumni relations, marketing and research.

Templates were designed for standardization of processes and communication and made it possible to ensure easy input, access and identification of pertinent information.
Because "process owners" or end users were engaged in designing the RMIS system, needs were met from the get-go. Supervisors' input was solicited at every stage about the how the system was being received and utilized. Even a glossary of terms was devised for standardized communication. For example, clients had been invariably referred to as guests, patients or clients; "client" became the standard moniker.

"When you design a system like this, or customize a standard electronic system, it is absolutely imperative to define the needs of your organization, including business system requirements," said Sam Dresser. "The requirement for standardization made us look at the scope of all documents and ask, is this truly needed?"

Dresser says that regardless of the complexity of an electronic system, running vendor tests is important. Finding out how the vendor will support the system with technical assistance, security back-up as well as availability of upgrades are all important considerations.
When RMIS was being planned, an outside technical consultant helped define parameters and system requirements. Choosing a Microsoft-based system was key because of their dominance in the marketplace, ensuring viability of RMIS support over the next decade. Having a strong IT infrastructure was also essential for implementing a system as complex as RMIS.

While RMIS is already five years old, an advantage of this proprietary system is its built-in capacity for continuing customization. One more recent function is a client scheduling system that customizes daily schedules for each inpatient client at Hazelden, Center City. Using a computer, a client simply clicks on his or her name and prints out a personal schedule.

The RMIS design stage took several years, and training is ongoing. Besides new clinician training sessions held once a month, refresher courses are offered when requested or on an as-needed basis and whenever new functions are installed. Current bulletins and newsletters are posted on the sign-in page.

"Initially accessing information and inputting clinical notes via computer was a significant leap for most clinicians," said Janelle Wesloh. "Clinicians used paper record keeping for assessment and treatment planning, but the hybrid record keeping system that predated RMIS only addressed pre-entry and continuing care functions. We maintain a technical help desk for assistance at any time, which is staffed by technically-trained clinicians, so they can relate to exactly what is needed," she said. "And having computer programmers in-house involved with the design of the system has been a real benefit to us in daily operation."

The RMIS clinical application: how it works

A client record begins at pre-entry and admission, when medical, chemical substance use, psychiatric and psychological history is gathered as well as financial and insurance information. The multidisciplinary clinical team includes but is not limited to therapists, counselors, physicians, nurses, psychiatrists and psychologists. A client's record will include assessments, medical and/or psychiatric diagnoses, updates, treatment care plans and notes, chemical dependency progress review, episodic notations, individual and group therapy records, discharge summary and continuing care plans.

All current and other pertinent information is recorded by appropriate staff and is accessed only by team members on a need-to-know basis. And clinicians can add on to a record, eliminating redundancies. If a client has previously been in treatment at Hazelden, those records can also be accessed by the appropriate clinicians in developing the current treatment plan.

Rather than rely on the time-consuming and often hard-to-read writing of individuals, specified team members record their notes by voice, according to the appropriate format. A team of trained transcribers records this dictation into the system's template forms. Reports are online within a 48-hour timeframe, with priority reports transcribed within 24 hours and critical reports on demand.

The RMIS system enhances quality of care by design, with specific record keeping throughout the continuum of care, and a new way for clinicians to share "in real time," accurate information that impacts outcomes. Supervisors regularly tap into randomly chosen clinical reports to address their accuracy and timeliness. And audits of health and treatment records at midpoint, or about Day 15 in inpatient care shows whether all pertinent information is in the file.

Marketing and research applications

Electronic record management systems in research and marketing applications not only make tabulation of data efficient, but also make it possible to design specific data gathering for numerous purposes. Hazelden's Butler Research Center's enhanced capabilities enable compilation and analysis of data more efficiently and accurately.

A marketing application includes an active client-tracking program, which is used to survey and tabulate data in demographic profiles according to trends. The employee can either pull up one of 100 standard reports, or can use a "data miner" to address specific queries on demand.

Security and disaster and recovery addressed electronically

RMIS has built-in controls for multi-levels of security. Clinical team members can click on pertinent information at any given time, but only on a need- to-know basis. The system automatically tracks whoever logs on to "what" information and "when."

Every administrator and computer user knows that when a system is down, everything can come to a screeching halt. But in health care, this may occur in a crisis or precipitate one. A back-up system and plan is absolutely critical to record management as well as client/patient care. Even with tape back-up, a redundant server is recommended so that there is never a chance of a critical information loss or interruption. Of course the on-staff IT team's work is geared to process maintenance and improvement of servers, network, telephones, firewalls and all electronic processes.

Archiving as well a destroying outdated employee and client records can be a time consuming task. With RMIS, outdated records are automatically identified at regular intervals throughout the year. Many treatment facilities and practitioners can relate to the necessity of storing multiple boxes of hard copy records. Record retention is driven by the highest given demands of both the federal and state regulations and statutes. In Minnesota, for example, inpatient record retention is required seven years from point of discharge, and for minors, seven years after the individual turns 18, so electronic record keeping saves clutter, time and money. For many facilities, microfilm or microfiche is another viable alternative to storing volumes of records.

Record keeping has become much more than the term implies. With the new electronic and hybrid systems available to treatment providers today, clinical tools offer streamlined communication and a more secure path to improve safety and quality of care. Does this mean clinicians can now carry larger caseloads? We don't see that happening any time soon. But these new management tools seem to help keep pace with the new complexities treatment protocols demand today.

The bottom line for all treatment and behavioral healthcare providers is the quality of care they can offer. As Sam Dresser succinctly put it, "No matter what type of electronic record management system it is, it's a dead system if it is not useable for the delivery of care."

Jackie Halderman is Media and Market Development Director at Hazelden and Joan Knight is a consultant. This article was completed with generous input from the following Hazelden staff: Janelle Wesloh, Director of RMIS and Privacy Operations; Sam Dresser, Manager of Business Application Projects; Sally Brandenburg, Director of Health Information and Quality Standards; Connie Robilliard, Supervisor of Heath Information Records; Ruth Mickelson, Supervisor of Health Information Transcription.

(Sidebar)
A short course on planning electronic record management

1. Determine what the system objectives and functions should be. Do you require cross-functional record management? Are there solid reasons to keep some paper-based processes? Are you currently using microfilm or microfiche?

2. Does your practice or facility have an internal IT staff or professional? Consider expert consultant(s), whether you are choosing an off-the-shelf or custom system. With the latter, ongoing management by a designated internal staff may be safer, more reliable and efficient long term, and designate a project manager.

3. When considering any electronic management system, find out its capacity for customization and upgrade and security back-up. A marketplace-dominant provider ensures better chances for long term system viability. Ask about availability of technical assistance, as well as training. Find out how the system has worked for a similar facility.

4. Get pertinent input and buy-in by those who will use the system. What are the specific needs and requirements of each function?

5. Standardize processes and communication to meet internal as well as all regulation needs. Remember: Security, Safety, Quality, Privacy. And don't forget ease of use. If the system is too complicated, or if there is more documentation built-in than needed, the resultant data won't be useful and staff will resist implementing the process.

6. Training should not only be initial, but in stages and certainly ongoing. Electronic record management as a clinical tool, for example, represents a departure in basic processes, and it will probably take more than "basic training" for clinicians to use it comfortably and automatically. Refresher courses motivate and educate.

7. Ongoing communication with stakeholders is critical in developing application upgrades.

This article is published in Counselor,The Magazine for Addiction Professionals, April 2005, v.6, n.2, pp.61-67

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