Managed care systems, although varied, share the common goals of cost containment and providing access to high quality mental health services. Despite claims to the contrary, the policies, procedures and techniques that comprise managed mental healthcare are an administrative burden on the provider. These administrative complexities have in turn challenged our management information systems. This observation is supported by Feldman (1992) in his book on Managed Mental Health Services, when he states that "There are few enterprises more information intensive than managed mental health and more dependent on good information systems for efficient operations, for evaluation and for effective quality assurance processes."
Many behavioral healthcare organizations are faced with the prospect of adapting to increased administrative and clinical management costs with reduced reimbursements.
One effective way to deal with these escalating expenses is through the strategic application of information technology. When selecting and implementing a new management information system it is essential in today's climate to design or select a system that incorporates the features required for managed care. The alternative is to supplement an inadequate legacy system with cumbersome manual procedures and partially automated applications. The latter approach, although initially less expensive and easier to automate, may have the undesirable effect of increasing labor costs while failing to generate the information required to be competitive.
"The wise choice for the vast majority of group practices and clinics involved in at-risk contracting is to purchase a full-featured computer system from an established vendor of healthcare systems" (Zieman 1995).
Managed care has had a significant impact on the need to automate. No other change in the industry has had as great an effect on the design and sales of information systems for the behavioral healthcare provider. In the past, many small practices were run quite well on manual systems or by simply automating the billing functions. Today in our era of healthcare reform and managed care it is a whole different ballgame. Not only are the requirements for client registration, billing and accounts receivable becoming more complex, but we are seeing a dramatic increase in the need for both accounting and clinical information. Additionally, many practices are becoming more and more dependent on office systems like word processing, spreadsheets, e-mail, and scheduling. Finally, we are seeing an increase in the need for electronic document imaging and electronic data interchange (EDI).
The MIS requirements can be broken down into six general categories:
- Client Information Management
- Accounting
- Clinical Records (basic charting functions, treatment planning, and clinical management functions)
- Utilization Management
- Office Systems
- Outcomes & Performance Improvement
Client Information Management System:
The basic client information management systems offered by the mental health software vendors typically include modules for scheduling, client registration, billing and accounts receivable. These were the first applications developed for the behavioral healthcare provider and are in many ways still the most important. One of the critical functions added to this suite of applications is managed care contract management. It is typically part of the billing and accounts receivable modules and is designed to manage client's benefits.
Accounting:
"In the accounting applications the four programs that are the most useful for managed care contracts include 1) purchasing, 2) payroll, 3) general ledger with budgeting, and 4) cost accounting. If the organization is a publicly funded agency like a mental health board or community based non-profit agency, a fund accounting general ledger is also useful. Many of the healthcare systems on the market have elected to partner with third party vendors for their accounting solutions. The interfacing of these systems has been greatly simplified with MS Windows and the emergence of ODBC and SQL standards.
Clinical Records & Pharmacy:
In the clinical applications, there are two general areas of interest: the basic charting activities and clinical management functions. The charting functions include scheduling, patient registration, assessments, treatment plans, clinical protocols, medication administration and drug formulary tracking, progress notes, and medical information. The clinical management functions include quality assurance/improvement, utilization review, credentialing, and clinical staff administration.
It is the automation of these applications which will provide the behavioral healthcare provider with the information necessary to evaluate and control cost, utilization, quality, and accessibility.
Utilization Management:
Beyond the documentation and charting requirements, managed care has resulted in the need for automated Utilization Management applications. These interface with each of the other five general information system areas and include:
- Admission Criteria
- Continuing Care Criteria
- Discharge Criteria
Based on the completion of "on line" forms and client information, these programs streamline the process of assessing type, level, and duration of care. Some may even correlate with a database of providers with specific capabilities matched to presenting problems, diagnosis, indicated treatment protocol and increasing, successful outcome and cost.
Office Systems:
Administrative operations, market research, consumer and payer interactions within a managed care environment require efficient word processing, communication, spreadsheet, database, presentation, and Internet capabilities.
More than stand alone functions within an office, these capabilities can be linked so the Community Relations specialist can gather market specific data, generate and mail a "Consumer Newsletter", track utilization patterns by payer or referral source, and quickly communicate plan or service changes to clinical and administrative staff.
Increasingly, a well organized, interactive web site may, for example, include an HMO's covered Drug Formulary, access and search capabilities for consumers who are members of a provider network looking for the nearest practitioner, or serve to promote a community mental health center's new children and youth "wraparound" program.
Outcomes and Performance Improvement:
Federal and state regulators, accrediting entities, employers, and advocacy groups now require not only service data (volume of clients, demographics, etc.) but also the outcomes of care. The Joint Commission for Health Care Organizations and National Committee for Quality Assurance both require significant performance improvement procedures and outcome measures designed to assess numerous dimensions of care.
These criteria can become quite extensive for public managed care initiatives, for example, a statewide managed Medicaid program.
Information systems are no longer just to "improve our efficiency". For outcome analyses related to performance improvement protocols, an information system capable of tracking, organizing, and complex analysis is mandatory. Manual systems would require far more human resources than agencies can afford and the vast amount of data necessary to conduct even basic analysis would be prohibitively time consuming to keep current.
The following bullets represent a sample of a Performance Improvement / Outcome application's capabilities. The system should be able to track and report on each of the following indicators, incorporating data from all other data sources and applications:
- Impact of care
- Aggregate service performance: number of cases, admission, discharges, etc.
- Service Procurement (Example: Time from call to intake.)
- Symptom Abatement
- Functional Level Change
- Severity, Intensity, Frequency of Impairment
- Length of Stay
- Over/under Utilization of Services
- Completion of Services
- Progress Toward Goals
- System Dependency
- Restrictiveness
- Recidivism/Readmission
- Cost per episode (how effective is the service protocol?)
- Cost per presenting problem
- Contract compliance
- Billing Accuracy: Exceptions, Denials and Timelines
- Preventable adverse outcomes
- Omission of treatment or administrative procedures
- Inappropriate utilization of resources, funds, programs, staff
- Difficulties in access, delivery, or coordination of care
- Access, availability, referral, triage
- Continuity of Care problems: transfers, referrals, outside consultations, etc.
- Client, Family, Purchaser dissatisfaction
- Amount of Intervention Activity
- Referral Source dissatisfaction
- Client Records Errors/Omissions (Chart Audit)
"All of the cost containment and quality management strategies and techniques employed by managed care carry with them significant implication for management information systems. The recognition of this fact is reflected in an article in Computerworld (10/25/1993).
"Healthcare chief information officers are finding that instituting healthcare reform will require complex new information systems, a big increase in IS spending and compliance with regulations overseen by a Federal healthcare bureaucracy."
The degree to which a provider, network and payer can automate its operations will have a significant impact on its ability to prosper during this era of healthcare reform and managed care.
About The Authors:
Bruce Johnson, M.S., PMP, is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with social service, healthcare, and government organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcsinc@fuse.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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