"We had more than 2 million client registration records in our legacy system, with many, many duplicates. We ultimately converted about 900,000 records in the initial cutover," says Dr. Paul Arns, chief of clinical informatics. Arns explained that records were de-duplicated and scrubbed, and then Netsmart helped load the records into the new system. With the need to synchronize IBHIS with the still active legacy system during the extended rollout period, DMH technical staff leverage a Netsmart-built web service to regularly "push" newly created legacy client and episode records from its data warehouse into IBHIS. Additionally, prior to each rollout, LACDMH has used the Avatar Data Import utilities to populate other critical information, like caseload assignments, in IBHIS. Arns adds, "With as many as 30,000 such records in a given rollout, a half day of processing data imports relieves several staff from four or five weeks of manual data entry that would needed for each rollout."
A few weeks before go-live, DMH sends a team of IBHIS analysts and support staff to review workflows and ensure the location is ready. On launch day, and for two weeks after, a team of Netsmart consultants work with an L.A. County implementation team, which includes business analysts and clinical staff from Clinical Informatics and Quality Assurance, as well as other IBHIS "Super Users" and Central Business Office staff to support the staff throughout the rollout. Arns says often there are hitches, glitches and several workflow tweaks in those first days, since despite all locations offering similar services, their staffing and workflows can be very different. The implementation team helps them make it through.
Super User is the term adopted by LACDMH for staff members with a special "go to" local support role during IBHIS implementation and ongoing operations. Netsmart Solution Architect Lynn Dudley partnered with LACDMH Senior Information Analyst Julika Barrett to produce a collaborative training plan for Super Users. The duo surveyed the L.A. County staff to determine who would need extra support and who might be able to assist others, ultimately identifying (with supervisors) who could be Super Users and who could be trainers of other Super Users and IBHIS end users. Dudley ran several four- or five-day trainings to prepare the IBHIS implementation Super Users. "Netsmart offers a valuable perspective," says Barrett. "They have worked with so many clients, they have a view of works and what doesn’t – and that’s helpful. Having a Netsmart peer to collaborate with was very important for me."
The training model used by San Antonio Mental Health Center in L.A. is one that Jennifer Hallman, IBHIS project clinical co-lead, recommends for other agencies. San Antonio’s Silvia Rowe set up a training room on site and worked with her Super Users to put together a series of trainings for her staff. After their initial IBHIS training, clinicians were required to attend for one hour per week, with the option for an extra hour of training for anyone who was struggling; the initial training identified on what topics to focus that extra time. However, as John Flynn, communications analyst for the LACDMH Enterprise Application Division points out, he only received about eight questions on the first day and when he offered answers, most staff quickly remembered their training. "It was a lot of, ‘Oh, yeah! Oh, yeah!’" he says.
"We have already received roughly $3 million in incentive funds for filing our purchase of an MU-certified EHR," says Arns. Now that L.A. County is about 80 percent through its implementation, LACDMH has assigned a team to manage subsequent MU requirements. He is optimistic that LACDMH will receive additional funds for each of its more than 200 Eligible Professionals.
"This has been a rapidly changing application," says Arns, who noted that while L.A. County managed to do five implementations in six months – between January and June 2014 – the county has slowed down now to optimize the system. Barrett says, "You have to manage expectations from the very start," noting that no one is going to walk out of training totally proficient. She also noted that because workflows can be so distinct from clinic to clinic, agencies should assume there will be three phases: implementation, utilization, and finally, optimization.
Dr. Zivoni Rozenblat: "I can access my clients’ files from Sacramento or the moon, which is a really good thing. With an EHR, you don’t have to search for a chart. I open my computer and see the client right away. And I also see if I made a mistake and can correct it. No one ever reviews paper records."
Psychiatric social worker Carmen Aguilar: "When dealing with a crisis, you have to do a very lengthy assessment. I was always playing catch up on my paperwork. It is much easier to type the interview as opposed to writing it."
Full Service Partnerships head Tosha Sweet: "The Netsmart CareRecord increases accountability. The system makes it easier for us to work together. We are always moving, and so it can be hard to touch base with someone face-to-face. This helps us so we don’t have to."
"A long-term partner," says Adrina Moreno, IBHIS project manager. She explains that while first an organization should vet solutions and ensure proper functionality, it is equally as important to find a strategic partner that can support clinicians with innovative solutions to navigate the ever-changing, accountable care healthcare landscape – proactively and effectively.
The Los Angeles Department of Mental Health (LACDMH) is a mini world. Serving greater than 260,000 people annually, LACDMH’s more than 4,500 employees see clients from across the behavioral and mental health spectrum – those suffering from depression, schizophrenia, bipolar disorder or co-occurring addiction. In addition to its directly operated service programs, LACDMH manages a large network of non-governmental contracted agencies.
The five directly-operated programs that serve an area in downtown L.A. known as "Skid Row" work with the most severely and persistently mentally ill -- people who hear voices, who are most often homeless. Lisa, a social worker for the county’s Downtown Full Service Partnership (FSP) program, tells of a young man who came in for treatment two years ago. He was crippled, homeless and excruciatingly angry at the world to the point that he lashed out and threatened the life of anyone who would try to talk with him.
"He wasn’t taking his meds and he had a lot of delusions," Lisa recalls. "For a very long time we had to hospitalize him once a week."
But somehow, Lisa built up rapport with the client. She was able to move him to be more medication compliant and his mood and psychosis leveled out so he could process his anger with her.
"He tells me now, ‘Lisa, I hated everybody and I couldn’t talk to anybody; something was blocking me and preventing me from doing that. Even when I yelled at you, I never hated you,’" says Lisa.
Lisa, like the other people who serve LACDMH, understands.
"There is so much pain that you have to deal with day to day. But when you see that a child is reunited successfully with his parent, or he comes back four or five years later and he’s clean and on his way to living a productive life – what better job can you do?" adds Lorraine Viade, supervising psychologist for LACDMH’s Metro North facility. "Is it hard? Yes. Worthwhile? Absolutely. I think I would do this even if I didn’t get paid."
LACDMH’s downtown clinics recently went live on the Integrated Behavioral Health Information System (IBHIS), LACDMH’s comprehensive behavioral health clinical, administrative and financial information system powered by a Netsmart CareRecordTM. The CareRecord provides both an electronic medical record (combing all data within LACDMH) and an electronic health record (bringing in the information from the external care providers). The rollout was the seventh of 12, with more than 3,000 users already live on the system.
FSP program supervisor Tosha Sweet says her team already sees the benefit of an electronic, coordinated system. In her unit, many appointments happen on the fly, more like an emergency room. In the past, because their workflow was so unstructured, appointments would never get entered, billing would be delayed and charts would be challenging to navigate. Now, she says, IBHIS is "creating mindfulness for us. … If we do it right from the onset, we won’t have to make it right later."
Sweet laughs, picturing the "big old box my clinicians had to schlep around" with charts and forms and other papers, which are now largely replaced by their laptop. The computer can access IBHIS anywhere there is an Internet connection, and they can take notes during field consultations or after an outreach encounter from wherever they are.
"I have been surprised how well it has worked," says Lupe Maldonado, an IBHIS analyst who has been with the project from its visionary stage in 2006.
What’s working is that the EHR captures data as part of each client visit, saving the time it would have taken a clinician to recap and document appointments at the end of their days in the past. Appointments are matched to services and progress notes, ensuring there is always clinical documentation for every client encounter and that these services can be billed or reported to the state. However, most importantly, a comprehensive assessment of the client is always available – to anyone who needs it. It isn’t in a big old box in the trunk of someone’s car, but rather in a secure, electronic record. Clinicians can check for adverse drug interactions, for allergies and suicide risk, so clients get better care and experience better health outcomes.
Continues Maldonado: "Every time a site goes live there’s a lot of anxiety and the people there are scared about whether or not they can do it. But it works – it really, really works."