Despite government incentive programs and a 2014 deadline for establishing a fully electronic health record (EHR) system, most health care transactions continue to be carried out manually, on paper.
Among impediments to EHR implementation: Financial—What will it cost? Training—How to prepare employees for advanced technology? Selecting a program—Outside vendors, an in-house system, or a combination? Personnel issues—Possible conflicts between confidentiality, privacy issues, and legal provisions?
To answer these questions, the National Institute on Drug Abuse (NIDA) awarded a grant to Addiction Research and Treatment Corporation (ARTC), one of the nation’s premier substance abuse treatment programs. A community-based, minority-operated, not-for-profit health care system with seven CARF-accredited opioid treatment programs (OTPs), ARTC serves more than 3,000 OTP patients each year in New York State, providing comprehensive methadone maintenance (MM) treatment, including HIV/AIDS services and primary medical care.
Lawrence S. Brown, Jr, MD, MPH, Interim executive director of ARTC, shares with us some challenges and opportunities ARTC encountered while implementing an EHR system under the NIDA grant. (The Journal of the Evaluation of Clinical Practice published a report; see citation at the end of this article.)
Setting up the ARTC EHR System
In 2006, ARTC began setting up EHRs for its general medical system, later interfacing it with the agency’s basic administrative needs. “We quickly realized we needed an outside consultant, because of the way our operations and systems functioned,” Dr. Brown says. “The project was beyond our in-house programmers’ scope, and rapidly changing technology was dating our software and hardware.
“As a not-for-profit, we obtain over 90 percent of our revenue stream through public funds. Hiring a consultant wasn’t an easy sell to our governing body, but we were successful, and the consultant began work in 2007. All staff received computer assessments, basic computer training, if needed, and specific program training.”
As a large, multiple-site OTP, ARTC needed to choose between upgrading their entire system and continuing to use a largely decentralized system, based on security considerations and operations. “This is a decision OTPs will need to make. For smaller OTPs, that’s less of an issue.” ARTC decided to upgrade their desktop computers, servers, and network, while ensuring continuity of billing and fiscal processes.
In 2009, ARTC’s general medical system went online. In 2010, behavioral data were integrated with the electronic medical system. Today, major challenges remain, as ARTC continues to integrate what was a largely paper-based information system with electronic clinical, administrative, and fiscal data.
Suggestions for OTPs Starting Out. Dr. Brown advises OTP staff to mentally prepare themselves before converting to an electronic system. “If you fight it, you’ll just become more frustrated.” Smaller OTPs considering starting a system internally need to carefully weigh the considerable start-up costs.
“Talk with your colleagues—OTPs who’ve set up a system, and those who haven’t—to identify the challenges. Find out how consultants have worked out for your colleagues.
“Do an in-depth needs-assessment of your OTP. Identify strengths, and areas for improvement. Involve all stakeholders, even though that’s a lot of work. Leaving out the governing body or clinicians would be a mistake.”
Some Things ARTC Learned
Importance of Timely Reports. “We began to see the relationships between the quality and timeliness of our reports, and the impact to our bottom line and to patient care,” Dr. Brown told AT Forum. “Before the electronic system, we couldn’t tell if we were getting timely reports. Some clinicians took days to complete their clinical records, and until they did we couldn’t submit bills. Now we are able to assess how promptly our clinicians carry out their clinical responsibilities.
”The electronic data also allow us to assess the quality of our patients’ treatment plans, and to determine if our clinicians meet the treatment requirements of federal and state authorities and professional accreditation organizations.
“Using the data, we’ve identified the items most important to our agency and field staff, leading to a hierarchy of objectives—our 5-point score card: 1) regulatory compliance; 2) financial health; 3) quality of care; 4) satisfaction of our patients and those we serve; and 5) satisfaction of our workforce. Whenever issues come up, we say, ‘Where does this fit in our score card?’ It helps us prioritize.” These scorecards can help an agency evaluate how effectively it meets goals and objectives.
Patient Confidentiality Concerns. “Patient advisory committees conduct ongoing patient satisfaction surveys at each facility. Addiction treatment presents confidentiality concerns, because protections are set to a higher standard than those for general medical care.
“We’ve made it clear that patient care trumps everything else,” Dr. Brown says. “We don’t disclose anything without patients’ permission, except what regulatory bodies require. We tell patients, ‘If your care is funded by a third party, that party has a right to your information. In fact, they have access to it already.’
“Within our agency, every clinician–whether in behavioral health or in the general medical field—has access to patients’ information. We will not allow patients to be harmed because a clinician lacks information.”
Cost Concerns. “Implementing a major change like EHRs always involves a learning curve, with an initial drop-off in productivity. And there are upfront costs for software and hardware, and possibly a consultant. The cost savings—return on investment—will probably take several years, regardless of the size of the OTP.
“Startup costs may be a greater challenge for smaller OTPs, but, importantly, EHRs will allow them to send electronic data to health departments, regulatory agencies, and other providers for care coordination, without increasing their costs. When small OTPs that have postponed going electronic need to send this data electronically, it raises personnel costs for data entry and quality control, and involves programming costs.”
Challenges ARTC Faced
Change Management. Various ARTC divisions had to collaborate in new ways—holding regular meetings for senior staff, formalizing strategic planning, agreeing on an integrated system, and coordinating software and hardware purchases: ensuring system compatibilities by planning installation under expert guidance, and well in advance.
Training Issues. ARTC evaluated all staff for basic computer skills and knowledge, and trained them to use software applications. “We assessed every employee’s computer competency–not to exclude them, but to find out their needs. Some required basic computer training as the stepping-stone to software they needed to do their jobs,” Dr. Brown says. “Over time, staff began to see technology as a way to improve their performance, rather than a threat to their employment.”
Electronic Security. Needs assessment revealed that ARTC was vulnerable to sabotage from within and without. To avoid database theft via flash drives, ARTC limited use of external media, disabled devices that write to media (with a few tightly controlled exceptions), changed the firewall, installed a spam blocker, and set up automatic locking at workstations. Updating electronic security remains a high priority at ARTC.
To successfully implement an EHR system, an OTP must carefully plan each step and involve all stakeholders in communication and collaboration throughout the development and implementation process. Studies suggest that the payoffs make EHRs worthwhile: better patient care and services, fewer medical errors, lower costs, better control over adverse effects of medications, a marked improvement in outcomes, and permanence of medical records during natural or wartime disasters.
Louie B, Kritz S, Brown Jr LS, Chu M, Madray C, Zavala R. Electronic health information system at an opioid treatment programme: roadblocks to implementation [published online ahead of print March 18, 2011]. J Eval Clin Pract. doi:10.1111/j.1365-2753.2011.01663.x.
For Additional Information
Government information sites have a wealth of helpful information about EHRs, government incentive programs, and funding details:
Information from the Department of Health and Human Services American Recovery and Reinvestment Act, Accelerating the Adoption of Health Information Technology: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__hitech_programs/1487. Accessed August 1, 2011.
Information on government incentive programs, including definitions, funding details, milestones, and timetables: https://www.cms.gov/ehrincentiveprograms/. Accessed August 1, 2011.