Challenges Of Implementing
An Electronic Health Record
Dennis Morrison, PhD
Chief Executive Officer
Center for Behavioral Health
Problems with Paper Records
A New Health
System for the 21st
Institute of Medicine,
Center for Behavioral
Overview of CBH
In existence since 1969
Private, Non-profit 501(c)3
CBH sees about 9000 clients per year
17% were seen for substance abuse treatment
21% were aged 17 or younger
5 MDs/5 APNs
Facility City Purpose
R & D Annex Bloomington Administrative
TCF Annex Bloomington Administrative
Recovery House Bloomington Housing
Blair House Bloomington Housing Note amount
First Street House Bloomington Housing
Swain House Bloomington Housing of housing
Hopewell Apartments Bloomington Housing and
Cardinal House Bloomington Housing
Wylie House Bloomington Housing residential
Westplex Apartments Bloomington Housing services
Bedford Apartments Bedford Housing
Mooresville Apartments Mooresville Housing
Martinsville Apartments Martinsville Housing
Fairview Apartments Bloomington Housing
Single Room Occupancy Bloomington Housing
CBH Bloomington Bloomington Outpatient Services
CBH Bedford Bedford Outpatient Services
CBH Mooresville Mooresville Outpatient Services
CBH Martinsville Martinsville Outpatient Services
CBH Spencer Spencer Outpatient Services
SouthPoint Psychological Services Mooresville Outpatient Services
Sydney Anderson, PhD Bloomington Outpatient Services
Clarizz (So Ind Peds) Bloomington Outpatient Services
Open Lot Bloomington Parking
Hoosier House Bloomington Residential Treatment
Transitional Care Facility (TCF) Bloomington Residential Treatment
Effect on Technology
CBH and Research
Committed to research-based treatments
Twenty two EBTs implemented
First Behavioral Healthcare provider to win
JCAHO’s Codman Award
Clinical data infrastructure core part of EHR
100% of clients measured on at least one and usually
several outcomes measures
Won the Davies Award 2006
Only Healthcare Organization of any kind to win
both the Codman and Davies Awards
s cr i b
nly Genoa Pharmacy
r sO On
Medication Sample Database
PCs Lab Portal
Thin Clients Core Application
1U Tape Backup
(Hoosier Assurance Plan)
CBH EHR Components
COMPONENT VENDOR APPLICATION PROCESS STATUS
Practice Clinical Charting Fully
Creative Socio- Prescriptions, Clinical Fully
Medics Charting Implemented
Image Scanning and Fully
Outcomes, Clinical Fully
Principia Remark Office
Decision Support Implemented
Handheld Pendragon Fully
Pendragon Mobile Charting
Data Entry Forms Implemented
Custom Treatment Plan, Fully
Development Progress Notes Implemented
Data Capture Goals of the EHR
Data capture matches workflow
Unidirectional or Interactive?
Cost effective (i.e. “cheap”)
Use what works, not what’s “sexy”
Clinical Outcomes must be integrated
Why do we need CDS?
It is now humanly impossible for unaided
healthcare professionals to possess all the
knowledge needed to deliver medical care
with the efficacy and safety made possible
by current scientific knowledge.
(Note: Good resource for basic info on Medical Informatics)
Information Change in
Some estimate that the half-life for Psychology
literature is 6 years.
This means that 50% of the information we have
today about psychology will be obsolete in 6 years
According to NIMH, it takes approximately 17
yrs for information to get from research to
This suggests that the old style of relying on clinical
researchers to keep us appraised of Best Practices.
Example: Assertive Community Treatment
EHRs allow in vivo studies and CQI loops to be
done in real time
An EHR is NOT an electronic
recapitulation of a paper record
The EHR can and should do things
for you that the paper record
Definition Clinical Decision
Clinical Decision Support Systems are
“…active knowledge systems which use
two or more items of patient data to
generate case-specific advice"
Wyatt J, Spiegelhalter D, 1991
Key Elements of CDS
Two or more pieces of data
Requires measurement or quantitative
information, not textual data
Yields clinical advice based on knowledge
“Advice” must be programmed into the
Who gets to decide? CEO? Clinical Director?
Vendor? State or National Norms?
Managing by Data
Behavioral Health Care is not good at this
Inertia (It’s an art, not a science)
State and Federal Regulations
First Question to be answered:
Is what we do measurable?
Goals for the CBH EHR
Ubiquitous Access of Clinical Records
No Paper Anywhere
Development of a Centralized Outcomes
Improved Security of the Clinical Record
1995 PC’s viewed as toys. WANG-VS Minicomputer was the “real”
Board agrees that major investments needed
Develop client-server environment
CEO bought the 1st server
1998 New Scheduling and A/R System
Architecture 1st, Functionality 2nd
2001 EHR implementation planning started
EHR Technology Implementation
Work Process Analysis & Improvement
Supportive & Ancillary Technology Improvement
2003 EHR implemented
2006 Clinical Decision Support System invented and installed
Upgrades and modifications ongoing
Director of Research and Clinical Informatics
Employee Focus Groups
All work flows mapped
Internal Marketing and Promotion
All Staff Meetings
Passing the competency became a condition
From 20 hours to as little as 1.5 hours
Moving From a Paper-centric Culture to a
Hardware, software, telecommunications
Easiest because they are tangible
“How will we practice differently with an
Harder because they involve people.
How do things get done now?
Non-clinical work processes can (should)
be changed long before the EHR is
What level of computer competency do we
expect from employees?
How will that competency be measured?
What personnel action will occur if an
employee is deficient in these
Teaching the Organization to
Does everyone in the organization have a
To what extent does the organization rely on
paper products for communicating?
Does everyone in the organization schedule
appointments electronically i.e. no “little black
Teaching the Organization to
To what extent is computer literacy required to work in the
Are new hires screened/tested for computer competency?
Is there an employee intranet for viewing policies etc
Are there personnel policies/procedures to deal with people who
cannot/will not use computers?
Is there agreement at the board level committing the
organization to a computer-centric culture?
How much communication between the Board and the chief
executive occurs electronically?
Does the Board have its own intranet for policies etc.
Similar to Evolution of CFOs
As CMHCs moved from grants funded to fee for
service models, “Controllers” became “CFOs”
and Executive Directors/CEOs had to learn new
Similar to Evolution of CFOs
Now “Managers of Data Processing” have
become “CIOs” and Executive Directors/CEOs
have to learn new skills again.
Unfortunately, this is harder.
What is the Goal?
Implement an EHR?
Manage the implementation?
Lead the organization?
The Goal is to change the culture of the
CEOs First Step
Edit the autocorrect feature in Microsoft
Word so “EHR” doesn’t automatically
change to “HER”
It’s the little things that people notice…
Contracts seem overwhelming
CEO’s aren’t technologists
Who do you trust?
CEO’s are accountable to the outcomes
The Role of the CIO
CIO hire is one of the most important
Tough hire: technical skills plus strategic thinking
Similar to Medical Director or CFO
Must learn enough to understand what they do
Must trust them enough to allow them to
Consider making a clinical informatics position
that can serve as “translator”
Key CEO Question
How will you know when you are done?
Clinical processes improved?
Better client services?
Identify this or you will never be done.
CEO’s Job in the EHR is Vision
Paint a picture of where the organization is
going and why.
The Real Challenge Isn’t
Changing the Culture
From what to what?
Paper records to electronic records? Or
Paper-centric culture to computer-centric
Cultural change is far more difficult
Work Process Improvements
The “how things get done” question
First: Map every process
“When you automate a mess,
what you get is a very fast mess”
What Can Be Compromised?
What must be done by when for whom?
“Gotta have vs. Wanna have”
"People are not your most important asset.
The right people are your most important
Who gets out of using the EHR?
This is how we do business now.