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Leveraging Technology to Support Behavioral Healthcare Management in Michigan

June 8, 2018
by Mark Hagland
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At the Community Mental Health Center of Ottawa County in Holland, Michigan, leaders are leveraging IT to improve care management

Community Mental Health Center of Ottawa County (CMHOC), located in Holland, Michigan, is a public provider of services for people with developmental disabilities, serious mental illness, and substance use disorders. The organization is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), and offers a range of programs from five locations throughout the county.  CMHOC is one of 46 community mental health centers in the state of Michigan; it encompasses about 105 staff members, two-thirds of them clinicians, and serves 3,200 active consumers of its services every year.

CMHOC has been using an electronic health record (EHR) from the Lisle, Ill.-based Netsmart, since 2005. Like many behavioral healthcare providers, CMHOC has had to adapt to funding reductions as well as significant changes in regulations, payment models and reporting data. Rich Francisco, deputy director of CMHOC, spoke earlier this year with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding the organization’s journey into automation-facilitated population health management and care management. Below are excerpts from that interview.

Tell me about the implementation and optimization of your EHR.

I came on board in 2011. The decision was made in 2005 to go to an electronic health record system, and at that point, they had switched from an old QS system to Netsmart. That’s when the decision was made to go paperless. And in 2011, when I came on board as the IT coordinator, they were on a version of Netsmart, Avatar, that had not been updated for some time. So my first order of business was to get it up to date. We skipped several versions of the software, including versions introduced in 2004 and 2006.

So there was a huge project we started with, which resulted in our decision to switch our parent module to using a practice management system. It was called the “flip project,” because we wanted to flip the two. myAvatar PM (practice management) module. We used to use MSO, which was the outward-facing provider module. Netsmart went through a thorough evaluation of how the product was being used, and that’s how we went with this.

Rich Francisco

What were some of the key issues involved in the transition for your organization?

The biggest thing we were trying to move away from was a heavy reliance on paper. Even in 2011 when I arrived, we were still very dependent on paper; we had a project, the health information management project, which involved converting our forms from paper to electronic, into the EHR. We’re talking about hundreds of forms, from assessments to tracking forms.

What kinds of efficiencies and benefits have you and your colleagues obtained in from getting away from paper in behavioral healthcare?

The biggest savings we achieved was achieving immediate access to information, and being able to analyze a lot of the data right away, and being able to report off it and analyze it, that’s one of the biggest values. We’re just getting to the point now where we’re beginning to be able to develop profiles of consumers in the system. And because we’re capturing all that data in the EHR, we’re able to develop a single view of a patient. And we’re able to track our costs through the system. We look at outliers through utilization management. And without going electronic, we could never have done this well.

But now, we’re able to run a good utilization management committee, in which we’re able to look at utilization and cost data, and benchmark our performance against the performance of peer community health centers, and that allows us to make decisions regarding practice. The fact is that behavioral healthcare has been years behind physical healthcare in digitization, because we didn’t have the incentives coming out of the meaningful use program.

So you’re trying to catch up, and do good population health and care management?

Yes, that’s absolutely right. Back in 2011, one of the first things I did was to sign a contract with Netsmart to pursue meaningful use. In the early stages, we were making sure we had all the elements in the EHR that would allow us to participate and get the incentives. So we had registered five prescribers in the 2011-2012 period, when we started the process of evaluation. We made sure to evaluate all aspects of the solution, from security issues, to making sure all of our prescribers, including our doctors, were registered.

I saw the value in it, because, first of all, we could shore up our EHR. And I said, we need to do this now, we need to invest in the product now, to make sure we’re compliant. And that was a good decision, because we’re able to report the data we need to report.

How many of your clinicians were eligible for meaningful use?

We have three who are registered—two nurse practitioners, and a psychiatrist.

Was it difficult to get them certified for meaningful use?

The product that we’re using had all the components. What was hard was the registration of prescribers. We had one who was already registered at a different agency, so we couldn’t claim them. Also during that time, we had registered agency-wide for meaningful use; so how did we get them to sign the funds over to us? Because we signed up as an agency, not as individuals, per the eligible professionals. That was the hard part.

So your EPs have received some funding from the meaningful use program?

Yes, that’s correct.

What have been the biggest lessons learned so far on this journey?

I would say it’s knowing your costs. It’s always been very difficult in BH to know your true costs. We’re operating off this historical model of basing funding on what it was in the previous year. Now, with everything accessible in the EHR, we’re able to leverage data in utilization management, to determine our costs. Is it at the level we should be, or over- and under-utilizing? Now, we have reports that tell us.

Have you been sharing data with any other community behavioral health centers in Michigan?

Yes, we’ve been participating with the Michigan Health Information Network (the East Lansing-based statewide health information network); we’re in the testing phases of getting admissions, discharge, and transfer data. That’s going right into the care record; and it would alert us to admissions, discharges and transfers, for our patients. It’s a one-way communication; they feed us the ADTs [admission, discharge, and transfer data].

And in the state of Michigan, we’re broken into regions. And we have five community health centers within our region; we’re one of five. And we’re exchanging data. Our data goes up to the regional entity, and we utilize another product for analytics, on that regional level.

What should healthcare IT leaders from any organization that you might collaborate with, know?

The biggest thing for me is to be able to share records with an agency that needs it, in the case of a transfer of care, or our provider network knowing that they’re entering physical health or being transferred to another care provider, being able to share that data. So from our local inpatient hospital here—let’s say one of our consumers presented at the ER; they should have our records in the ER. And there’s some effort taking place at the state level now, with that. But that should also be taking place at the local level.

What’s next for you and your colleagues, in all this?

For me, it’s really shoring up our outcomes basis and value basis. We’d like to become more standardized in terms of our local efforts. I’d really like to be able to have a standardized recommendation for level of care, that comes out of the ANSA—the Adult Needs and Strengths Assessment—[the a multi-purpose tool developed for adult’s behavioral health services to support decisionmaking, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services]. I’d like to be able to have a standardized output for level of care, out of that assessment, utilizing data. We’re also evaluating other tools for other assessments as well. These assessments might be for substance abuse; might be for the assessment of children. The next step would be to come up with an appropriate level of care, using these standardized assessments, and then to develop a standardized recommendation. But the algorithms need to be built in.

Given the kind of progress that you and your colleagues at CMHOC are making, how fast will such progress be evolving forward across the U.S. healthcare system, in the next few years?

All of our partners have rolled out the ANSA in some fashion. We rolled out the ANSA for our organization, in the past year. And the region has hired Integrated Health Analytics, it’s a PhD statistician with a couple of master’s-level statisticians, to produce the algorithms we need to determine level of care. We should have a standardized protocol for recommendations for next level of care, out of that. In Michigan, it’s all recommendations, because it’s delivered for patient-centered planning.




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Study: Clinical Decision Support EHR Alerts Can Lower Health Costs, Complications

August 20, 2018
by Rajiv Leventhal
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When physicians follow the recommendations of context-specific clinical decision support at the point of care, clinical and financial outcomes should improve, according to new research.

Researchers, in the recent study, published in the American Journal of Managed Care, examined more than 26,000 patient encounters to determine whether utilization of clinical decision support (CDS) is correlated with improved patient clinical and financial outcomes. In the treatment group, the provider adhered to all CDS recommendations, while in the control group, the provider did not adhere to CDS recommendations.

The analysis examined the associations between adherence to recommendations from Choosing Wisely—a clinical decision support platform from Stanson Health—embedded into clinical decision support alerts, and four measures of resource use and quality.  They found and concluded:

  • Encounters in which providers adhered to all alerts had significantly lower total costs, shorter lengths of stay, a lower probability of 30-day readmissions, and a lower probability of complications compared with nonadherent encounters.
  • Full adherence to Choosing Wisely alerts was associated with savings of $944 from a median encounter cost of $12,940.
  • Health systems should consider real-time CDS interventions as a method to encourage improved adoption of evidence-based guidelines.

In 2012, the ABIM Foundation—a healthcare quality organization devoted to advancing medical professionalism—introduced the Choosing Wisely (CW) initiative, a voluntary effort by more than 70 physician subspecialty societies to identify commonly used low-value services, with the intent to stimulate provider–patient discussions about appropriate care and thereby reduce low-value tests and treatments. But initial research of the CW recommendations found that providers had difficulty interpreting guidelines and evaluating patient risk.

To this end, the researchers attested that an EHR (electronic health record) infrastructure could provide real-time computerized clinical decision support to inform healthcare providers when their care deviates from evidence-based guidelines. CDS comprises a variety of tools, including computerized alerts and reminders with information such as diagnostic support, clinical guidelines, relevant patient information, diagnosis-specific order sets, documentation templates, and drug–drug interactions.

For this study, CW recommendations were implemented in the EHR at a large academic health system in the form of 92 alert-based CDS interventions, both inpatient and ambulatory. When initiating a potentially inappropriate order, a provider received real-time notification of deviation from a CW recommendation. That provider then had the option to cancel, change, or justify the order, if he or she agreed with the alert’s recommendation in the context of the individual patient.

It should be noted that two of the study’s authors are employed by Optum, which is a licensed reseller of Stanson Health, including its Choosing Wisely alert content evaluated in this study. What’s more, another of the authors is employed by Cedars-Sinai, which is the major shareholder of Stanson Health.

In the end, the researchers recommended that health systems consider real-time CDS interventions as a method to encourage improved adoption of CW and other evidence-based guidelines. A meta-analysis of CDS systems concluded that by providing context-specific information at the point of care, the odds of providers adopting guideline recommendations are 112 times higher.

They concluded, “Our findings contribute to the evidence base surrounding the use of CDS and improvements in patient clinical and financial outcomes. Formal prospective cohort studies and randomized CDS intervention trials, perhaps randomizing providers assigned to receive CDS interventions, should be prioritized to help guide future provider strategies in regard to reducing low-value care.”

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Study: Many U.S. Hospitals won’t Reach HIMSS Stage 7 Until 2035

August 14, 2018
by Rajiv Leventhal
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Unless the healthcare IT ecosystem experiences major policy changes or leaps in technological capabilities, many hospitals will not reach Stage 7 of HIMSS Analytics’ Electronic Medical Record Adoption Model (EMRAM) until 2035, according to new research.

The study, published in the August edition of the Journal of Medical Internet Research, analyzed Healthcare Information and Management Systems Society (HIMSS) Analytics’ EMRAM data from 2006 to 2014.

HIMSS Analytics is the research arm of the Healthcare Information and Management Systems Society (HIMSS). HIMSS Analytics developed the EMRAM in 2005 as a methodology for evaluating the progress and impact of electronic medical records on health systems around the world. Tracking their progress in completing eight stages (0-7), hospitals can review the implementation and utilization of information and technology applications culminating with Stage 7, which represents an advanced electronic patient record environment. Other Stage 7 requirements include: leveraging an external HIE (health information exchange); use of a data warehouse; and having robust data analytics functions.

The researchers of this study noted that the meaningful use (MU) program has promoted electronic health record (EHR) adoption among U.S. hospitals. And while studies have shown that EHR adoption has been slower than desired in certain types of hospitals; generally, the overall adoption rate has increased among hospitals.

However, the researchers continued, these studies have neither evaluated the adoption of advanced functionalities of electronic health records (beyond meaningful use,) nor forecasted EHR maturation over an extended period in a holistic fashion. “Additional research is needed to prospectively assess U.S. hospitals’ electronic health record technology adoption and advancement patterns,” the researchers stated.

The HIMSS EMRAM data set was used to track historic uptakes of various EHR functionalities considered critical to improving healthcare quality and efficiency in hospitals. A technology diffusion model was then used to predict the technological diffusion rates for repeated EHR adoptions where upgrades undergo rapid technological improvements. The forecast used EMRAM data from 2006 to 2014 to estimate adoption levels to the year 2035.

In 2014, more than 5,400 hospitals completed HIMSS’ annual EMRAM survey (86 percent of total U.S. hospitals). Back in 2006, the majority of the U.S. hospitals were in EMRAM Stages 0, 1, and 2. But by 2014, most hospitals had achieved Stages 3, 4, and 5, the study noted.

The researchers found that in 2006, the first year of observation, peaks of Stages 0 and 1 were shown as EHR adoption precedes HIMSS’ EMRAM. By 2007, Stage 2 reached its peak. Stage 3 reached its full height by 2011, while Stage 4 peaked by 2014. This forecast indicates that Stage 5 should peak by 2019 and Stage 6 by 2026, according to the data revealed in the study.

The researchers noted, “Although this forecast extends to the year 2035, no peak was readily observed for Stage 7. Overall, most hospitals will achieve Stages 5, 6, or 7 of EMRAM by 2020; however, a considerable number of hospitals will not achieve Stage 7 by 2035.” They concluded, “These results indicate that U.S. hospitals are decades away from fully implementing sophisticated decision support applications and interoperability functionalities in electronic health records as defined by EMRAM’s Stage 7.”

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HHS OIG Fines eClinicalWorks $132,500 For Violating Corporate Integrity Agreement

August 1, 2018
by Heather Landi
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The Health and Human Services (HHS) Office of Inspector General (OIG) fined electronic health record (EHR) vendor eClinicalWorks $132,500 for failing to report patient safety issues to the regulatory body as reportable events in a timely manner.

According to the OIG website, eClinicalWorks paid the fine July 18. The EHR vendor is required to report these patient safety issues to OIG as part of its corporate integrity agreement (CIA) with the agency.

eClinicalWorks entered into a CIA back in May 2017 as part of a settlement with the U.S. Department of Justice to resolve a False Claims lawsuit. According to the DOJ’s case, the company allegedly violated federal law by misrepresenting the capabilities of its software and for allegedly paying kickbacks to certain customers in exchange for promoting its product, according to the U.S. Department of Justice. As part of that settlement, eClinicalWorks also paid a $155 million settlement over the allegations.

The five-year CIA requires, among other things, that the company retain an Independent Software Quality Oversight Organization to assess eClinicalWorks’ software quality control systems and provide written semi-annual reports to OIG documenting its reviews and recommendations. The company must provide prompt notice to its customers of any safety related issues and maintain on its customer portal a comprehensive list of such issues and any steps users should take to mitigate potential patient safety risks.

Further, the agreement also requires eClinicalWorks to allow customers to obtain updated versions of their software free of charge and to give customers the option to transfer their data to another EHR software provider, without penalties or service charges. The vendor must also retain an Independent Review Organization to review its arrangements with healthcare providers to ensure compliance with the Anti-Kickback Statute.


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