Selecting a Behavioral Health Information System

Marc Andrews
Joe Ambrosino

February 23, 1998

Introduction
Problem Statement
Organizational Background
Players
Proposal
Evaluation of Available Systems

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Rapid changes in technology are causing sweeping changes throughout every walk-of- life in the United States and the behavioral health field is certainly no exception. In the past, the field's need for information management was limited. Most computer-based applications were clinical, rather than administrative or managerial, in focus. These applications were used for patient testing and for assistance with evaluation and diagnosis. Beyond that, some behavioral health programs and practices used computers for billing. Community mental health centers used computers for reporting to appropriate funding agencies. Academic behavioral health professionals used computers for research. However, all in all, there were few information systems.

In today's era of managed care financing and delivery of behavioral health treatment services, the need for information has changed dramatically. Access to information has indeed become critical. Today's behavioral health program uses its information system to track patient care, test the assumptions of treatment plans, communicate with payers and other providers, submit and pay claims, determine and analyze costs, and manage pools of patient funding.

Meeting these functional requirements is still not enough. Today's behavioral health information systems must be integrated. The information systems function that tracks patients must communicate with the system functions that monitors treatment plans, which must communicate with the function that submits claims and so on.

The technology is not the only problem for most behavioral health organizations. There is a wide array of software and hardware available that can constitute a system solution for most behavioral health organizations. The challenge lies rather in building the human interface with the computer system. The successful behavioral health organization needs executives and managers who are comfortable with computer-based information and the systems needed to manage it. These same organizations also need staff at all levels who are computer literate. This requires fundamental changes in the roles and responsibilities of most behavioral health professionals.

The integration of Information Technology into a behavioral health setting can be a challenging proposition. While there have been some meager attempts at the use of IT in the medical record systems in some large health care institutions across the country, there has been even less in community mental health centers. This results primarily from three factors: the low-tech nature of behavioral health, the high reliance on clinical knowledge, and finally the prohibitively high cost of IT in a poorly funded sector. In order to survive and even thrive, behavioral health providers and facilities will need to capitalize on the potential benefits of electronic medical records. These benefits include increased quality of care, efficiency of process, and containment of costs.

Allegheny East MH/MR Center, Inc. is a multi-faceted community-based agency serving mentally ill and mentally retarded children and adults residing in the eastern suburbs of Allegheny County. It was founded in l969 in response to the Pennsylvania Mental Health and Mental Retardation Act of l966.

Over the past 28 years, Allegheny East has grown from a small outpatient program to a multi-faceted agency providing case management services, outpatient treatment, 24 hour emergency services, day and evening partial hospital programs, training and social rehabilitation programs and many levels of supervised residential programs for MH and MR clients. The agency employs over 250 staff and has an annual operating budget of over $10 million. The major portion of this revenue comes from the County contracts, and additional revenues come from fees for services paid by clients, Medicare, Medicaid, contracts with behavioral health managed care entities, school districts and other organizations. Allegheny East has a Joint Venture with Forbes Regional Hospital for its inpatient services and works with the Office of Vocational Rehabilitation, several public school systems and the Allegheny Intermediate Unit, CYS and many other agencies.

There are four sites, as well as on-site services such as those that are school based. We have 24 FTE professional staff consisting of licensed social workers, psychologist, master's level psychiatric nurse, and master's prepared counselors. There are three full-time psychiatrists and four part time contracted psychiatrists. There are support staff such as aids, nine secretarial/billing related and medical records staff, and all departments depend upon, and interact with, several other departments such as the information systems, billing department, and the base service unit which provides intake, case-management, registration and records departments.

1. State Government: As a CMHC licensed by the state, they yearly review our clinical performance. This includes review of our clinical medical records to see that they comply with state policies. Thirty-percent (30%) of our reimbursement for services comes from the State.
2. County Government: As a CMHC licensed by the County, they yearly review our clinical performance. This includes review of our clinical medical records to see that they are in compliance with state policies. Thirty-percent (30%) of our reimbursement for services comes from the County.
3. Third party payers: Forty percent (40%) of our reimbursement comes from twenty-five (25) different third party payers. Each of these payers has various rights to review various medical information contained within the medical charts to determine medical necessity and authorize payment for services.
4. Clinical Staff: The clinical staff is the primary user of the medical chart. This is where they document the progress of their clients, monitor treatment goals and progress towards those goals. Since we are a multi-site entity, clinical staff sees clients in many different locations. This means that paper work and the chart must be transported to these various locations. This is often a logistical nightmare.
5. Clients: Clients who have the least to do with the physical chart are the ones who benefit the most by their proper maintenance. Since all historical-clinical information is retained in the chart and used by the clinical staff to determine on- going treatment needs, the more real time access that clinical staff can have to this information the better they are able to provide quality care.
6. Administration: Administration uses the information contained within the medical record for billing, contract compliance, demographic reporting, and management decision making concerning staffing needs, productivity of staff, internal quality review, payer mix, client mix and so on.

We will review and evaluate several behavioral health clinical practice management programs. The evaluations will be conducted in the following process.

1. Defining Functionality
1. "Must have" vs. "Desirable" requirements of the system
2. Constructing scenarios: Develop actual events, that occur frequently during operation or events that may happen in the future. Determine the system's ability to handle these scenarios.
3. Surveying Vendors
1. Formulate cost parameter.
2. Survey vendors on their system's functionality
1. Seek-out publicly available product reviews
3. Solicit information from others who are currently using systems
4. Selecting a System

In the past, each constituency would choose the application that best fit their particular needs. What resulted was a collection of individual applications that could not interface with each other. This has created an additional administrative burden in trying to get diverse systems to "talk" to one another. In an era of shrinking reimbursement, increasing regulatory reporting, and managed care demands, this inefficiency is no longer acceptable.

The decision becomes: Can we afford to allow each constituency to choose the "optimal" system for their "individual" needs or should we evolve to an integrated system, that, while it may be sub-optimal for any one particular area, serves the overall organizational needs best.

The preliminary decision is that if there is a system on the market that will provide the overall organizational needs while still providing acceptable standards for individual constituencies, then an integrated system would be desirable. The first step of the process was to survey the needs of the "customers", or individual constituencies (clinicians, front desk, etc.) to determine what aspects of an information system are absolutely critical ("must have") vs. those functions that would be desirable, but not essential.

Once we determined the needs, we surveyed all known vendors for documentation on their system's functionality as well as demonstration disks on their product and estimates on the cost of implementing their system. In addition, we independently sought out publicly-available product reviews in professional publications as well as the Internet. We also solicited feedback from other organizations who have already implemented any of these systems. The following systems were evaluated but did not sufficiently address overall organizational needs to warrant final consideration.

ASD Software, Aeolian Systems and Design: Office Manager. Comprehensive patient record-keeping and billing software. Simple to use. Progress notes of any length, customized intake, discharge, treatment plan forms, HCFA's, invoices, past-due statements, labels, password protection, counts authorized visits, much more. IBM, Windows, Macintosh. Standard version $495. Demo disks $15.

Avebury Computing Ltd., MidexPro 4.08 is a very complete program for managing any private medical office for any specialty. It is not restricted to mental health. A free full working version with all options is downloadable from their web address. Programmed in Visual Basic. IBM, Windows. Single practice version f495, word processing option f185, expense option f85, diary option f170.

Beaver Creek Software, The Therapist V.3.1 -- Professional Office Management Software -- full-scale billing program, fills in forms, all diagnostic codes (DSM-IV, CPT, RSV, ICD-9), prints on letterhead or new HCFA 1500, for up to 99 therapists, makes mailing labels, deposit slips, tracks referrals and pre-authorizations, clinical notes, password protection, backup and restoration of data, pre-authorizations and insurance maximums, dunning messages, form letters, etc. IBM, Dos $249 + $10 shipping. $15 for full demo which works for 60 days. $99 for ECS, $199 for custom report writer.

Cambridge Software Labs, The Cure. "Organizes, manages, and automates every aspect of your practice." Up to 99 therapists, referral tracking, correspondence, scheduling, checkbook, mailing labels, graphs, calculator, passwords, reminders, etc. Write notes, calculator, checkbook, multiple providers. ECS scheduler, IBM, DOS, free demo disk (specify 3.5" or 5.25"). $50 for demo and manual. $550-$895.

Community Sector Systems, Inc., Psych Access 2.0 is an "electronic clinical information system" of charting and data management. Tracks meds, lab results. Does managed care reports, impairments, treatments, treatment plans, progress notes, authorizations, etc.. ECS. IBM, Windows. Currently in pre-release testing for $29. Regular prices$695 or $995 with one-year online support, but current prices $300-350.

Decisionbase 2.5. A clinical system, not office management. Interactive history taking, DSM-III-R (not DSM-IV) diagnosis and treatment plans, progress notes, graphing and statistical analysis of progress and lab results, WAIS-R and WISC-R interpretation, word processor, reference to 500 journal abstracts, "on-line textbook" offers descriptions and treatment recommendations, for IBM,DOS, $595/US. Decisionbase Plus is the granddaddy of these programs.

Decisionbase Plus -- 3,000 journal abstracts to support treatment decisions. IBM, DOS, $695/US. Free sampler; specify disk size.

Echo Management Group, Clinician's Desktop is part of a very comprehensive, multi-component MIS for non-profits in any mental health area. WINDOWS. Approximately $6,000. Demos available. Unix, DOS as well. Download a demo from their website.

Micro-Eye. Psychotherapy Office Planner. Billing and office management. Designs forms, customizable statements, DSM-III and CPT codes, session notes when used with a word processor, checkbook, supports IRS 1040-C. ECS and multiproviders are options. Prints on HCFA 1500 or plain paper. Requires Microsoft Excel ³ 3.0 (IBM or Mac). Unlimited phone support. For Windows or Macintosh, $195 plus $15 shipping. $100 for multi-provider, $300 more for ECS. Demo $12.50.

O.M.S., Touched. "The ultimate therapist management program." Instant Secretary: Does diagnoses, treatment plan, progress notes, appointment scheduler, address book, contact tracking, medical history, etc. Instant Accountant: Thorough billing. Instant Assistant: Spell checker, intake and history guides, questionnaire builder, graphing of data, envelope and label printing, periodic reports, etc. Instant Fairy God-Mother: on-line help, networking, passwords, multiple therapists, etc. Treatment plan builder. Seems extraordinarily complete. IBM, WINDOWS. 5 therapist group $659.00, $25.00 for each additional therapist, $100 for 5 additional therapists. Solo system $527.00. Billing only $299.00. Super Lite $179.00. Free Demo available. Trial system $9.00 with manual on disk, $21.00 with printed manual.

PC Consulting Group, Delphi/PBS: Psychotherapy Billing Software. Very complete package: assessment forms design, billing, accounting, diagnostic codes, mailing labels, on-line help, payroll calculation, clinical notes, scheduling, electronic claims submission, backup, passwords, built-in backup, finance charges, etc. Toll-free phone support. Free updates IBM, DOS and Windows and all networks. $895 for solo, $100 per each additional clinician. Free demo for 2 months "evaluation package" with toll-free telephone support, manuals, (applicable toward purchase price). Demo downloadable from website.

The Psychotherapy Practice Manager (TPPM) provides complete control of your practice with client records (client registration, intake interview, and assessment, progress notes), billing (individual and batch, client, adjusted for anticipated insurance payments, HCFA 1500 forms, labels), appointments (scheduler, reminders, "To Do" lists), Rolodex (sorting codes, address books, labels), general ledger (revenues, expenses, profit and loss, IRS 1040 Schedule C summary), management reports (accounts receivable, aging, detailed and summary activity), DSM-IV/CPT codes, generic forms (consent to treat, release of information, etc.). Built-in tutorial, etc. 90 days free technical support, managed care, custom reports, ECS, networking etc. available. Single therapist version for DOS or 68x MACINTOSH $295. For WINDOWS 3.1 and 95 or POWERMAC $395. Versions for multiple-therapist practices are $100 more). Full-featured demo $20, credited toward purchase.

We then systematically ranked each system against the pre-determined needs of our organization. While we started with fifteen (15) potential choices, it became clear that only three (3) of the systems were serious contenders for system-wide implementation. After narrowing the field to these three possibilities, we constructed several "real-life" scenarios and tested each system's ability to respond to the scenarios.

The systems are also ranked according to pre-determined cost parameters. While functionality is a higher priority than cost, obviously, there is a point at which the cost of a system would outweigh its benefits.

QuicDoc is a Clinical Information System that documents patient care, measures therapeutic progress and treatment outcome, and assess quality of care. Computer generated intake reports, progress notes, discharge summaries, treatment plans, and quality assessment reports are easily individualized. Extensive clinical data lists ( e.g., medications, treatment goals, impairment, etc.) are supplied for report generation. There are more than thirty (30) lists of which the user can customize from the main menu.

Analysis of numerous variables entered during the course of documenting patient care comprise the quality assessment component of QuicDoc. Quality assessment reports can be generated for specific providers, programs, managed care companies, and or by date or date range.

Quality assessment reports summarized a number of variables such as:

• Average number of sessions seen by diagnosis


• Age and sex characteristics


• Differential GAF by diagnosis


• Number of patients by diagnosis


• Outcomes of care


• Breakdown of patient satisfaction ratings

You can score and graph the results of outcome measures provided for children, adolescents, or adults. QuicDoc includes the Health Status Questionnaire, Timberlawn Child Functioning Scale, Survey of Sysmptons-77, and the OQ-45 to measure outcomes for individual patients or evaluate aggregate data. You can also input the results of the Beck Depression Scale, Geriatric Depression Scale, SCL-90-R, or any other measure, and QuicDoc will track the progress and report on aggregate results. In addition, QuicDoc includes a Patient Satisfaction Survey to assess consumer satisfaction.

• The intake note features nine content areas: diagnosis, presenting problems, history, symptoms, functional impairments, assessment, outcome, treatment plan, and goals, each with a tabbed interface for easy movement from section to section.
• The progress note allows entry or a number of content and process characteristics of sessions, interventions utilized, response to interventions, and discharge planning.
• The termination summary allows for recording discharge type (e.g., mutually initiated), discharge status (e.g., improved), reason for discharge, and discharge recommendations.
• Incidental notes can be used to document contacts other than formal therapy/evaluation sessions, such as calls to or from the patient, family members, etc.
• The Outpatient Treatment Plan displays symptoms and treatment goals based on the diagnoses entered.
• QuicDoc's Scheduler allows you to graphically maintain and track appointments and manage short and long range tasks with its, "to do list" function.
• QuicDoc provides a number of forms and letters such as Release of Information, Consent for Psychotherapy, and model letters to referral sources and patients. Forms and letters can be edited according to individual needs.
• Password protection with a user ID and password insure confidentiality of records.

Very comprehensive multi-functional program: billing/accounting, word processor, progress notes, customizable screens, mailing labels, phone/address book, pop-up warning screens, automatic calculation of copayments, etc. for managed care. Networkable. Codes for DSM, ICD, CPT, HCFA 1500 forms completion. 400+ context-sensitive help screens. Networking included. Open (not proprietary) database. Therapist Scheduler and "Insurance Connector®" for ECS at extra cost. IBM, DOS, Windows. $495 for solo, $200 per therapist after the first, $97 for starter version (same as solo, but limited to 12 or fewer patients), free literature, $5 for DOS or Windows demo.

• Insurance connector is a time-saving electronic claims process which allows transmittal of client data quickly and reliably to hundreds of insurance companies.
• Libraries store essential information such as DSM codes, names and addresses of insurance companies, referrals sources, therapists, managed care organizations, etc.
• Easy to use, extensive help menu, dedicated technical support.
• Flexible reports on everything from billing and payment to referral sources
• Scheduler is integrated with billing, including automatic posting from schedule to accounts receivable
• Multiple therapist' schedules
• Managed care authorizations warn when clients approach authorization limits based on sessions, dates, or dollars for capitated cont4acts.
• Processes patient insurance billing transactions, accounts receivable, statements and tracks payments.

The CMHC/MIS includes a full complement of data processing functions, which are carefully engineered to provide an orderly, integrated process. For example, the entry of data to describe a service simultaneously affects the distribution of personnel time, revenue earned, accounts receivable, cost of service, and clinical records. The system supports all parts of the organization: administration, clerical, financial, clinical and general management.

Functions include:

• Client/Patient Data: The CMHC/MIS is able to store virtually unlimited amounts of data about the people you serve: identification, demographics, clinical data, third party eligibility, etc.
• Integrated Service Notes: This multifaceted function integrates several clinical features in the MIS including: treatment planning, tracking the status of treatment plan elements, automating the service notes as text in the client's record, maintaining a direct relationship between clinical notes and the treatment plan, and achieving auditability of service events which require notes.
• Planned Events: The CMHC/MIS helps plan and track future events, appointments, follow-ups, treatment plan goals, staff meetings, clerical and administrative activities. The system simplifies staff time reporting by printing the scheduled events for each staff member.
• Service and Event Data: The CMHC/MIS provides extensive capture and reporting functions for service data. Services may include direct events such as therapy, medication, testing, residential days, and daily census. The system can also account for support time, clinical and administrative activities, and even personnel time such as vacation and sick leave. The system automatically computes fees and determines the appropriate third party, if any. Service data also provides the basis for revenue accounting, client and third party billing, payroll distribution, costing, budgeting, and cash receipts posting.
• Accounts Receivable/Billing: The CMHC/MIS greatly improves cash flow through a complete, comprehensive, and fully integrated Accounts Receivable/Billing process. When a service is recorded, the system determines if it is billable and whether the recipient and service are eligible for third party reimbursement.
• General Ledger: The general ledger is the focal point of all CMHC/MIS financial processes, relating to all other functions through detailed journal entries. This integral design centralizes financial records, eliminates redundant manual posting, and provides a complete audit trail.
• Payroll: Using information from the personnel and services functions, the CMHC/MIS payroll process computes earnings for salaried and hourly personnel and prints checks for any desired pay period.
• Budgeting: The CMHC/MIS has a unique design that recognizes three types of budgets. The trial budget, the original budget, and the actual budget.
• Financial Reporting: The CMHC/MIS provides many standard financial reports such as budget vs. actual, current period and year-to-date, revenue/expense by cost center, etc. For additional reports, the system includes an extremely powerful Financial Report Generator (FRG).
• Cost Analysis and Reporting: The Cost Analysis and Reporting function of the CMHC/MIS is a sophisticated statistical tool used for computing the cost of service.
• Vendor Data and Accounts Payable: The CMHC/MIS eases the time consuming process of handling purchase orders, invoices, disbursement checks, and the associated accounting for budgets, encumbrances, and expenses.
• Purchasing: The purchasing system will print purchase orders to send to suppliers.
• Inventory: The CMHC/MIS inventory system is fully integrated with purchasing, payables, and the general ledger.
• Report Generators: Is able to produce an extensive array of reports to support managed care, case management, billing, accounting, inventory, etc. Altogether, there are over one hundred standard reports.

After evaluating all these systems, it was felt that the CMHC system clearly provided the most comprehensive, integrated IT solution for the organization. The system supports all aspects of the practice: administrative, clerical, financial, clinical, and general management. It integrates these various areas into a seamless system that automatically links data entry describing a service to personnel time requirements, revenues, costs, accounts receivable, and clinical records related to that service.

CMHC offers flexible scheduling capabilities with a simple interface that allows appointment searches based on multiple search parameters. It fulfills financial and business requirements including electronic billing, account receivable tracking, general ledger, payroll, and budgeting. In addition, it meets all of the administrative requirements related to reporting to outside regulatory and managed care entities.

Although CMHC offers the most complete integrated system, this does not mean it is necessarily the best system in every particular aspect. In fact, clinicians preferred the QuicDoc system's clinical component. They felt that QuicDoc provides a more comprehensive, flexible clinical component with an easier interface. While, ideally, clinicians would prefer QuicDoc, CMHC did meet all of their "must have" requirements and was an acceptable alternative to them.

A second factor in the selection of CMHC/MIS is that five years ago Allegheny East purchased the CMHC package with the intention of implementing the various modules over the years. The first module to be installed was the accounting module. For the past five years all accounting functions have been executed and stored on the CMHC system. In assessing which practice management software would provide the greatest value to the organization we had to consider that a vital function of our organization has been processed on the CMHC system. And that this system clusters all other practice management functions around the accounting module. Since Allegheny East has this foundation in place, the CMHC systems is the logical choice for the implementation of the clinical practices management system.

While evaluating, testing and selecting systems is a monumental undertaking, it is really only half the battle. The most prolific technology is only as good as the people using it. The challenge lies in integrating the information system with the human component. Not only must executives be adept at managing information technology, but they must provide the leadership necessary to articulate to staff the importance of information technology to the organization's survival.

The greatest challenge will be the providers. Health care providers, and particularly behavioral health providers, tend to be very resistant to any change that they fear may adversely impact patient care. They are understandably, more interested in the human, one-on-one provider to patient relationship and they see information technology as an intrusion on that relationship. Any effort to bring them on board will need to focus on ways an integrated information system will help them treat patients more effectively, and make their jobs easier.

ASD Software, Aeolian Systems and Design, P. O. Box 10874, Rochester, NY 14610. (800) 313-8133. Robert Hale. E-mail: rhale@eznet.net January 27, 1997

Avebury Computing Ltd., Clevedon, Brays Lane, Hyde Heath, Amersham, Bucks, HP6 5RU, England. Telephone/Fax: +44 (0)1494 776142. E-mail: midexpro@avebury.co.uk. January 27, 1997

Beaver Creek Software, 525 SW 6th St., Corvallis OR 97333-4324. Sales (800) 895-3344, business (541) 752-5039, support (541) 752-7563, fax (541) 752-5221. Peter Gysegem, President. January 2, 1997

Brand Software, Inc., 500 W. Cummings Park, Ste. 3150, Woburn, MA 01801. Sales: (800) 3-HELPER, support: (617) 937-0080, fax (617) 937-3232. http://www.helper.com. Cheney Brand, Pres.

Cambridge Software Labs, 45 Highland Road, Boxford, MA 01921. 508-352-8909. Paul M. Peckins, LICSW, January 27, 1997

Community Sector Systems, Inc., 700 Fifth Avenue, Suite 5500, Seattle, WA 98104. 800-988-6392, fax206-467-9327. E-mail: Mail@cssi.com, http://www.cssi.com. January 27, 1997

Decisionbase, Suite 8110-420, 264 H Street, Blaine, WA 98230, (604) 876-2254. 1206-750 West Broadway, Vancouver British Columbia V5Z 1J2. Philip Long, MD. E-mail: pwlong@mental http://www.mentalhealth.com. Note: this is a very rich site. January 27, 1997

Echo Management Group, 1620 Main St., P.O. 540, Center Conway NH 03183. 603-447-5453, 800-635-8209, fax: 603447-2037. E-mail: sales@echoman.com
http://www.echoman.com. January 27, 1997

Micro-Eye. 17560 County Road 85B, Esparto, CA 95627. (800) 787-3194, fax (916) 787-3993, 76012,2207 CIS. January 27, 1997.

O.M.S., P.O. Box 661, Nevada City, CA 95959. 1-800-588-6824. http://www.oro.net/~oms E-mail: oms@oro.net. January 27, 1997.

PC Consulting Group, P. O. Box 69382, Portland OR 97201. (503) 246-7858. (800) 847-8446 sales (and toll-free support). http://www.delphipbs.com/~wpardy Will Pardy. January 27, 1997.

Psychotherapy Practice Manager (TPPM) 113 Hueneme Ave., Channel Islands, CA 93035. (805) 983-3791, (800) 895-1618. E-mail : jhmullin@anacapa.net. Web: http://www.anacapa.net/~jhmullin. Jay Mullin. January 27, 1997.

CMHC/MIS, 570 Metor Place North Dublin, Ohio 43017 (613) 764-0143 http://mis.cmhc.com .

Mental Health Connections Quick-Doc, 21 Blossom St., Lexington, MA 02173. (617) 860-7544. Mhc@mhc.com, http://www.mhc.com Robert Patterson.

Managed Care Strategies, "Technology Primer: Practical tips for behavioral health groups". October 1997, Volume 5, Number 10. Pp. 7-8.

Behavioral Health Management. "Behavioral Health, Inc: Anatomy of an Information System Purchase". Henry Yennie. January / February 1996. Vol. 16, No 1. Pp. 24-25.

Behavioral Health Web Sites:

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