Behavioral Health and the EMR

Why One Psychiatric Hospital Went Open-Source

Sigurd Ackerman, M.D., is president and medical director of Silver Hill Hospital, a 129-bed inpatient psychiatric hospital in New Canaan, Conn. Like many leaders in behavioral healthcare, Dr. Ackerman found when seeking an updated electronic medical record (EMR) system for his standalone psych hospital (which is affiliated with the medical school at the Yale University School of Psychiatry), that the options were relatively limited, and in many cases not advanced enough for his institution’s needs. Dr. Ackerman spoke recently with HCI Editor-in-Chief Mark Hagland regarding his organization’s experience on its EMR journey.

Was this your first EMR?

No, this was our third. I got here about eight years ago. In the late 1990s, one of my predecessors had brought in an EMR, but for various reasons, the medical staff didn’t like it and essentially didn’t want to use it, so the hospital in effect just dropped it. It appears that there was inadequate preparation and training the first time around. So basically, everything went back to paper [after the failure of the first implementation]. Meanwhile, we had a couple of good people here, and they had developed a business and registration system from [the Boca Raton-based] Eclipsys [Corporation]. And there was a lab system and a pharmacy system, but no clinical system. Actually, the first thing I had to do was to bring e-mail into the hospital, in 2003. They were still on voice-mail. Then, around 2004, I decided it was time to look at an electronic record. I had previously been at St. Luke’s-Roosevelt in New York and had brought in an EMR in the mid-90s. During my time at that organization, we had put together a task force to look around the country for an EMR solution; and what we found in the 1990s was that the big, proprietary, off-the-shelf systems did not have much for psychiatry. They’re great if you’re with the department of surgery or whatever, but apparently, there’s so little revenue to work with in terms of the psych hospitals, that there hasn’t been much development.

So we went with a psychiatry-specific EMR developed by an academic medical center. It had all the stuff you’d need, screen by screen, and it had great drop-downs. We brought that in around 2004 or 2005, and spent a lot of time selling the idea to our staff, and training people, and it actually worked well. And we got to the stage where we thought we would do order entry and link everything to lab and pharmacy, but found out you almost couldn’t do it. For example, there was no way to look at clinical episodes; it was just one big clinical flow in the system. So you couldn’t look at the last admission. You couldn’t interface that system with anything or work with episodes, so it really only worked as an electronic chart. We were 80-percent paperless, but I decided that the only way to move forward was to abandon that system, which had cost about $800,000 including training and all its components.

So we looked again, and found the same thing all over again. But this time, I came upon the fact that there were now a couple of companies that had gotten the VistA system from the VA [the federal Veterans Administration health system], through Freedom of Information. And so I hired a very good consultant with whom I had worked in New York City a couple of times, and he had helped hospital systems go live over the years. And I was also the president of the hospital, so I had that experience as well. So he was a huge help and helped us vet the idea of the system, and Medsphere per se [the Carlsbad, Calif.-based Medsphere Systems Corporation], because I was very concerned about going with a new company, etc. But in the end, we liked what we saw.

Interestingly, the VA system hadn’t been significantly developed for psychiatry, either, even though they do a lot of psychiatric treatment. And what these companies [Medsphere and others] are marketing is not the code, but service. And they were willing to work with us, and we’ve made a lot of adjustments in the system. Here’s an example of what they don’t have in most systems. All the regulators require a multi-disciplinary treatment plan (the Joint Commission, CMS, etc.), and that is a treatment plan in which the psychiatrist, the social worker, the nutritionist, the occupational therapist, and whoever else is involved, must sign off on the plan. It’s a single document that everyone contributes to. So it’s a very different kind of situation than with a typical inpatient medical record in a general inpatient hospital, which is about individual clinicians performing individual tasks. There’s no convenient way to do a multidisciplinary treatment plan in most electronic health records; they’re just not built that way, particularly with regard to multiple sign-offs by everybody.

So you had to do this on your own?

Yes. And we’re not done yet;  we’ve completed the first phase. We developed, ourselves, a kind of workaround at the go-live phase last February. When we went live, we had a workaround that was awkward and time-consuming, but it got you there. And now we are about to introduce, with Medsphere, a version of a multidisciplinary treatment plan, in which everything lands on the same page with multiple signatures. And there will be a further advancement on that.

What is the timeframe for that further development?

Within the next couple of months. We’re working on it right now, and we’ve worked with them on the architecture, and they’re working on the program changes.

So you’ve been live since February, then?

Yes.

What have you learned so far?

Well, we’ve certainly learned how important it is to work with your staff, both to sell the product internally first, and then to train vigorously before you begin exposing them to the system. For example, we had a fair number of local super-users who were really trained up. We have a lot of sites here—there are 43 acres and 10 different buildings here. So we need super-users all over the place, and in many cases, with 24-hour coverage, because we have residential programs here. And we had a leadership pair of two people who were superb—one was an IT person, and one was a social worker who happened to be responsible for our quality performance program and who knew the hospital well. Together, they developed a leadership team that was multidisciplinary. And this leadership team put together, before going live, all the tasks that needed to be addressed before we went live, and then worked with subgroups throughout the hospital to accomplish specific tasks. And one of the things we had here was the opportunity to rethink the clinical workflow. So rather than just saying we wanted the screen to automate current processes, we really changed our workflow as well, as part of this. And that involved a lot of work, but I would do it again that way.

Do you believe that what you’re doing could be replicated in other psych hospitals?

Yes, absolutely, in psych hospitals, in psych departments in other hospitals, in community health centers; because one of the advantages of OpenVista [the VA-based, open-source product that Medsphere helps its customers to implement] is that somebody could learn from this, as we could learn from others. So there’s a kind of efficiency of sharing there.

Has anyone from other psych hospitals expressed interest in your implementation?

Yes, there’s a little network emerging, and we’ve had a number of other hospitals and health systems visiting here and expressing an interest. I can’t mention names, but the group has included some statewide organizations.

There has been some discussion in Congress about extending stimulus funding, and therefore meaningful use, to psych hospitals.

Yes, though it wouldn’t help us in a particular anyway, because we only have about 5 percent Medicare. The inpatient is almost entirely commercial insurance.

Clearly, there is a need for the commercial EHR/EMR vendors to step up to the plate here, correct?

Absolutely. And one of the things we were kind of betting on is that the idea of using the VA system’s IS would be appealing to many, and that there would be a degree of sharing here. The VA’s system isn’t the fanciest system, but it’s very robust. It’s a MUMPS-based system.

How have your clinicians reacted?

People like it a lot. They were already satisfied. And the addition of order entry makes it very workable. And order entry is in there; it’s the multidisciplinary treatment plan that is the workaround. And there’s a barcoded eMAR [electronic medication administration record]in there also; it’s actually rather sophisticated. We’re fully paperless, except for prescription-writing, which we’ll certainly do at some point.

You don’t have a CIO, then?

No, we have two very good IT people, and the rest are clinical people who have worked hard on this. And the senior operating people, including me and the COO, have worked hard on this. That’s the other factor involved; you’ve got to have some clout to make it work.

Click on OpenVista and Psychiatry to access Mark Hagland's interview in Healthcare Informatics.