Home
EHR system for Outpatient Mental Health
Simplicity, ease, completeness, competence
System Q is a software package; a comprehensive electronic documentation system designed exclusively for outpatient mental health services and incorporates standardized forms provided by the Massachusetts Standardized Documentation Project (MSDP). The system automatically generates and routes documents and allows for comprehensive management of client electronic health records, in accordance with the 2014 federal mandate.
The software design has simplicity thus eliminating unnecessary screen changes and complicated navigation. There is ease with user interface because the navigation is intuitive and concise. The system follows a prescribed workflow designed for outpatient treatment documentation. Completeness is achieved with a comprehensive system that automatically generates and routes documentation. All clinical documents are accounted for. It also allows administration to track and monitor performance. Professional/clinical competence is insured with the use of standardized forms, provided by the MSDP project. The forms assist clinical formulation, planning, treatment, outcome measurement, quality assurance, and support the ‘medical necessity’ of treatment. The system prevents lost revenue due to insurance ineligibility, scheduling inefficiency, and late or missing billing; insures appropriate records for regulatory compliance and most importantly, promotes “great clinical and business practice”.
Standardized Clinical forms
Medical Necessity
“The type, intensity and duration of an intervention as provided by a qualified practitioner and ordered by a qualified practitioner in the current action plan is needed to prevent worsening and/or produce improvement of symptoms, behaviors and/or functioning level related to an approved diagnosis and assessed needs”
Massachusetts Standardized Documentation Project (MSDP)
The goals of MSDP are to develop a standardized set of clinical forms that will lead to improved quality of patient care; increased compliance; and more efficient business practices.
Quality of Care Benefits:
- Promotes consistent assessment, planning & service documentation
- Person-Centered and Strengths focus
- Recovery/Resiliency focus
- Promotes Information Sharing
- Promotes effective collaboration with other providers & shared terminology for use by different disciplines
- Less room for error; Decision support
Business Benefits:
- Compliant with Federal Mandate for Electronic Health Records by 2014 & a wide variety of regulatory and payer requirements
- Protection against federal audits
- Enhances Measurement & Outcomes Focus
- EHR Vendor Certification Process to help ensure that the EHR product you purchase is compliant with the MSDP data elements
Cost savings
Un-rendered billing
Revenue is lost due to delinquent treatment plans/reviews and progress notes submitted late, or not at all.
There are several common areas that mental health providers lose revenue. The primary source is psychotherapy progress notes being submitted either late or not at all. Few clinics have a mechanism or system to track un-rendered progress notes and delinquent treatment plans/reviews. It is the responsibility of each psychotherapist to insure timely completion and submission of treatment plans/reviews and progress notes. Currently this profession maintains an honor system only. It is typically the multidisciplinary team that identifies missing progress notes upon file review, at which time it is too late to appropriately bill for those services. It is not uncommon for clinics to lose revenue for one progress note per fulltime psychotherapist each week. This easily translates to thousands of dollars of lost revenue per week. Many psychotherapists skip paperwork submission deadlines because documentation is time consuming, in addition to their already full work schedule and the emotionally demanding nature of services provided.
This system provides accountability! Supervisors and management are provided with a simple, yet comprehensive tool to monitor performance. The best way to remedy un-rendered paperwork is to provide accountability, via a preventative tool.
Ineligible billing
Revenue is also lost due to insurance ineligibility for both psychotherapy and psychiatry services.The next most expensive area for lost revenue is insurance ineligibility. Most psychotherapists are not notified of their client’s insurance ineligibility in a timely manner. They are usually notified after seeing clients, at which time the services provided are non-billable. Being notified in a timely manner will prevent interruption of care and allow psychotherapists to notify clients of interruptions in their insurance coverage. It is usually the responsibility of psychotherapists to communicate insurance eligibility with clients. This system provides prompt communication with psychotherapists to effectively address insurance eligibility issues and appropriately schedule client appointments.
Psychiatry is similarly affected. Most often the psychiatry department is not provided notification of insurance ineligibility. Usually there is only a mechanism to alert psychotherapists, thus leaving psychiatry vulnerable to continued non-billable services. This system provides psychiatry with prompt communication as well. In this manner, psychiatry can notify clients, reschedule appointments, and maintain consistent billable services.
Audit competence
Missing documentation is a critical and common issue when client health records are reviewed by an auditor. Missing treatment plans/reviews and missing progress notes leave mental health professionals (psychotherapists and psychiatrists alike) vulnerable and subject to high fines and/or strict corrective actions plans, as enforced by insurance providers and federal and state regulations. Fines are extrapolated across all billed services based upon the audit sampling, which combined with corrective action plans can severely affect business operation. It is imperative that client health records are complete and maintain integrity. The system enables management to monitor and maintain health record compliance and integrity. The system automatically protects against human error and/or poor performance. In addition, the system also provides tools for improved clinical formulation and clinical description of medical necessity, thus increasing clinical competence and reducing risk of audit issues related to clinical content of client health records. In summary, this system greatly improves integrity, completeness, and competence of health records.