HomeMy WebLinkAbout1415-8 Behavioral Health Software Implementation follow-up report (Final...Follow-up report of Behavioral Health - Software implementation #14/15-8 June 2015
FOLLOW-UP REPORT
Behavioral Health - Software implementation
(Internal audit report #12/13-3 issued May 2014)
To request this information in an alternate format, please call (541) 330-4674 or send email to David.Givans@Deschutes.org
Deschutes County,
Oregon
David Givans, CPA, CIA, CGMA
Deschutes County Internal Auditor
PO Box 6005
1300 NW Wall St
Bend, OR 97708-6005
(541) 330-4674
David.Givans@Deschutes.og
Audit committee:
Shawn Armstrong, Chair - Public member
Chris Earnest - Public member
Lindsey Lombard – Public member
Gayle McConnell - Public member
Michael Shadrach - Public member
Jennifer Welander - Public member
Anthony DeBone, County Commissioner
Nancy Blankenship, County Clerk
Dan Despotopulos, Fair & Expo Director
Follow-up report of Behavioral Health - Software implementation #14/15-7 June 2015
TABLE OF
CONTENTS:
1. INTRODUCTION
1.1. Background ………………………………………...………………................................... 1
1.2. Objectives & Scope ……………………………………..………………………….…….… 1
1.3. Methodology ……………………………………………………..…………………….……. 1
2. FOLLOW-UP RESULTS ……………….…...………………………….............................. 2
3. APPENDICES
3.1. Appendix I – Department memorandum for follow-up (dated 6/5/15) ................... 3-9
3.2. Appendix II –Updated Workplan (Status updated as of June 2015) .................. 10-11
Follow-up report of Behavioral Health - Software implementation #14/15-8 June 2015
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1. Introduction
1.1 BACKGROUND
Audit Authority:
The Deschutes County Audit Committee has suggested that follow-ups occur from nine months to one
year after the original report issuance. The Audit Committee’s would like to make sure departments
satisfactorily address recommendations.
1.2 OBJECTIVES and SCOPE
Objectives:
The objective was to follow-up on the outstanding audit recommendations.
Scope:
The follow-up included nine (9) recommendations from the internal audit report on Behavioral Health -
Software implementation (#12/13-3 issued May 2014).
The follow-up reflects the status as of June 2015. The original internal audit report should be referenced for
the full text of recommendations and discussion.
1.3 METHODOLOGY
The follow-up report was developed from information provided by David Inbody, Operations Manager. In
cases where recommendations have not been implemented, comments were sought for the reasons why
and the timing for addressing these. The follow-up is, by nature, subjective. In determining the status of
recommendations that were followed up, we relied on assertions provided by those involved and did not
attempt to independently verif y those assertions.
The department provided a memorandum detailing their current activities addressing the recommendations
and their transition to a new software system. This memo is included in the Appendix.
Since no substantive audit work was performed, Government Auditing Standards issued by the Comptroller
General of the United States were not followed.
DESCHUTES COUNTY
INTERNAL AUDIT
REPORT
DESCHUTES COUNTY
INTERNAL AUDIT
REPORT
DESCHUTES COUNTY
INTERNAL AUDIT
REPORT
Follow-up report of Behavioral Health - Software implementation #14/15-7 June 2015
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2.
Follow-up
Results
Figure I -
How were
recommendations
implemented?
The follow-up included nine (9) recommendations. Management agreed with all of the recommendations.
Figure I provides an overview of the implementation status of the recommendations. The details of the
updated workplan are provided in Appendix I and II.
With this follow-up, all of the recommendations are still underway. As indicated in their memo, they
anticipate implementation of the software in the Fall of 2015.
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3. Appendices Appendix I – Department memorandum for follow -up (dated 6/5/15)
Memo
To: David Givans
From: Dave Inbody
cc: Jane Smilie, DeAnn Carr, Michael Ann Benchoff
Date: June 5, 2015
Re: Audit Followup – Electronic Health Records System
In May 2014, a Deschutes County internal audit was released regarding the Behavioral Health electronic health records (EHR) system.
Through this audit, the following concerns were identified:
1. Profiler lacks effective internal controls to assure compliance.
2. A survey of Profiler users indicated an overall dissatisfaction with the system.
3. Profiler implementation work continues.
4. Profiler disruptions are numerous and impact productivity.
5. The measurement of staff productivity is difficult.
6. System lacks effective audit process for the Quality Management team.
7. Audit log controls are insufficient.
In response, the Deschutes County Health Services Department (DCHS) presented a strategy to address these concerns to the Audit
Committee on August 21, 2014. The primary emphasis of this presentation was the decision by the Health Services Department,
Behavioral Health Division, to transition from the current Profiler EHR system to the Epic EHR system. The Epic system is currently
used by the Public Health Division. The following comparison between Profiler and Epic was provided to identify the justification for
pursuing this planned transition.
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Concern Current (Profiler) Proposed (Epic)
Effective Compliance Internal controls require County
development Inclusion in statement of work
User Dissatisfaction Multi-screen user interface PH support & fiscal staff satisfied;
behavioral health professionals use it
Ongoing Implementation System updates and testing County
responsibility
System updates and testing OCHIN
responsibility
Disruptions Loss of data creates liability risk and
negative financial impact
No server issues or loss of data reduces
risk and protects billing
Measuring Productivity Report development County’s
responsibility; no collaboration Collaborative reporting capabilities
Quality Management Fails to meet 4 of 21 minimum compliance
standards; system overhaul required Inclusion in statement of work
At that time, the following timeline was provided for successfully completing this transition. DCHS can report that this plan is on schedule and
the “go-live” date for the transition from Profiler to Epic is planned for September 18, 2015.
Action Time Frame Participants
Statement of Work 3Q14 EHR Team; Transition Team
Contract (finalize statement of work) 3Q14 Health Svcs; County Admin; OCHIN
System Build 4Q14 – 2Q15 OCHIN
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Action Time Frame Participants
System Rollout & Training Plan 1Q15 EHR Team; Transition Team
System Training 2Q15 OCHIN
Program-Specific Training 2Q15 EHR Team; Health Services Staff
Go-Live 3Q15 Health Services; OCHIN
OCHIN, the organization DCHS is contracting with for the Epic EHR system, is redesigning their current Behavioral Health module to better
address the needs of their clients. As part of the scope of work for this build, an itemized list of all DCHS required changes to the current
OCHIN-Epic Behavioral Health module was included. This scope of work, agreed to by OCHIN, is currently being addressed through bi-weekly
design meetings between OCHIN and DCHS clinicians and EHR staff. DCHS is also meeting bi-weekly with a work group of all OCHIN
Behavioral Health clients in addressing improvement to the module.
The original audit provided nine specific recommendations in addressing the concerns the audit identified. Here is an update on the
department’s progress toward addressing these concerns.
Software system currently lacks effective internal controls to assure compliance
Recommendation #1: It is recommended for DCHS management to put in place sufficient controls to assure compliance
requirements are met whether they be through software design or through additional review by staff.
The Systems Performance Team (formerly the Quality Management Team) conducts quarterly data integrity audits on Behavioral Health staff.
These audits identify errors in documentation and are intended to meet federal and state compliance requirements. In the most recent data
integrity audit, the department achieved a 88% compliance rate.
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A site review was conducted by the Oregon Health Authority (OHA), the Addictions and Mental Health Division, for the department’s
recertification as a provider of mental health services and substance abuse disorder services, as required by the Oregon Administrative Rules.
The following organizational strengths were included in the site review final report.
Changes in the compliance and quality assurance department have been witnessed in the quality of documentation. Service
plan structure met all rule requirements and objectives were measureable and observable. Assessments were updated annually
and written thoroughly and succinctly.
Great improvements in quality management and quality assurance since the last review. Clinicians and managers reported
having pride in their QM numbers which in turn leads to more ownership of their work and of the agency as a whole.
Staff productivity is still in question
Recommendation #2: It is recommended for the department to institute sufficient controls over services to assure they are being
captured and billed. To the extent needed, the department should gain better understanding of the extent services being provided
by provider.
The department instituted productivity standards for all clinicians last year. Each clinician is provided an annual productivity target. This, as well
as other departmental actions, has resulted in a steady increase in billed services over the past year. The following graph represents the value
of billable services by quarter.
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Recommendation #3: It is recommended the department find and enforce a solution to its scheduling needs that better addresses
client and organization needs.
In the FY 2016 DCHS requested budget, a scheduler position was requested. This position will be responsible for scheduling all
Behavioral Health appointments. Currently, this is the responsibility of each individual clinician. The addition of a scheduler will not only
address the concern identified by the County Auditor, but is expected to improve productivity and provide more rapid rescheduling of
missed or cancelled appointments. The FY 2016 Deschutes County budget is expected to be adopted by the Board of Commissioners
during the last week of June.
$-
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
Encountered (Billed) Dollars
1st Qtr 2014
2nd Qtr 2014
3rd Qtr 2014
4th Qtr 2014
1st Qtr 2015
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Quality Management Team can audit more effectively
Recommendation #4: It is recommended the department, after considering the integrity of the software product and data, available
staffing and the progress of implementation, coordinate the compliance efforts between billing and the Quality Management Team.
Success in addressing this recommendation are explained in response to recommendation #1 and recommendation #2.
Recommendation #5: It is recommended the department work toward utilizing the data in the software system to develop a
coordinated quality review process for billing and quality management.
The department holds monthly meetings of the Systems Performance Committee to review and analyze the latest data to assess quality and
productivity. The following comment was provided in OHA in their site review final report.
Systems Performance Committee is collecting and analyzing data to provide improvements and program design needs, as
well as developing excellent reports for outcome measurements.
Recommendation #6: It is recommended the Quality Management Team focus their audit efforts on quality and compliance efforts
that require more skilled assessment of clinical documentation once they have addressed the more basic compliance efforts within
the system.
Within the last 12 months, the Systems Performance team has hired three new staff members. These new staff members are more
broadly skilled in the areas of quality and compliance, but also are adept in performance management and data analysis. Additional
comments in addressing this recommendation appear in response to recommendation #1.
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Audit log controls insufficient
Recommendation #7: It is recommended for department to establish appropriate audit logs and the underlying oversight and
reporting to assure the software is working as intended.
Although this was not fully achieved with Profiler, the transition to Epic will be able to successfully address this concern.
Recommendation #8: It is recommended that appropriate policies and procedures be in place for handling of the audit logs.
The department is currently in the process of redesigning the current structure of departmental policies and procedures. This revision includes
the updating, and where necessary, addition of new procedures. This initiative will result in addressing this recommendation. Epic will also
better facilitate this effort as compared to Profiler.
General software control observations
Recommendation #9: It is recommended the department assess how they could address identification of clients and appropriate
limiting of printing and exporting of clinical records.
Clinical records are only printed and/or distributed as required by coordination of care procedures with external providers. Paper charts are no
longer maintained DCBH. Any historical paper documentation is scanned into the EMR. The department has one Registered Health
Information Technician (RHIT) and is in the process of hiring a second RHIT. These positions are responsible for ensuring the department’s
practices are not in violation of HIPAA and any other confidentiality requirements.
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Appendix II –Updated Workplan for Report #12/13-3 (Status as of June 2015)
Rec# Recommendation Agree
Status Updated Department comments
Estimated
Date
1
FINDING: Software system currently lacks effective internal controls to assure compliance.
It is recommended for DCHS
management put in place sufficient
controls to assure compliance
requirements are met whether they
be through software design or
through additional review by staff. Agree
In
progress
DCBH has acquired authorization to transition its
Electronic Health Record system from Profiler to
OCHIN (the EMR used by the Public Health
division). This transition is currently underway and
full implementation will occur August 2015. Fall 2015
FINDING: Staff productivity is still a question.
2
It is recommended for the
department to institute sufficient
controls over services to assure
they are being captured and billed.
To the extent needed, the
department should gain a better
understanding of the extent
services being provided by
provider. Agree
In
progress
DCBH has fully implemented productivity
expectations and tracking and has seen a steady
increase in OHP encounter data. Fall 2015
3
Same as above
It is recommended the department
find and enforce a solution to its
scheduling needs that better
addresses client and organization
needs. Agree
In
progress
All direct staff have their schedule available within
the EMR. DCBH requested a Main Scheduler
position in FY 2016 budget proposal. This
position will manage clinician appointments for
greater ease and consistency of scheduling. Fall 2015
4
FINDING: Quality Management Team can audit more effectively.
It is recommended the Department,
after considering the integrity of the
software product and data,
available staffing and the progress
of implementation; coordinate the
compliance efforts between billing
and the Quality Management
Team. Agree
In
progress
The DCBH documentation compliance has
exceeded its target of 92%. The new EMR will
have additional "stop gaps" in the system to
prevent potential compliance errors from
occurring. Fall 2015
Follow-up report of Behavioral Health - Software implementation #14/15-7 June 2015
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Rec# Recommendation Agree
Status Updated Department comments
Estimated
Date
5
Same as above
It is recommended the Department
work towards utilizing the data in
the software system to develop a
coordinated quality review process
for billing and quality management. Agree
In
progress
The DCBH Systems Performance Program utilizes
data within the EMR to generate monthly reports
and dashboards to provide ongoing quality and
compliance information. Fall 2015
6
Same as above
It is recommended the Quality
Management Team focus their
audit efforts on quality and
compliance efforts that require
more skilled assessment of clinical
documentation once they have
addressed the more basic
compliance efforts within the
system. Agree
In
progress
DCBH's current Data Integrity Rate is 92% and
the department has received confirmation from the
April 2015 state site review that documentation is
both compliant and of high quality according to
state standards. Compliance and quality audits
will continue to be performed on a quarterly basis
to ensure ongoing adherence to rules and
regulations. Fall 2015
7
FINDING: Audit log controls insufficient.
It is recommended for the
Department to establish
appropriate audit logs and the
underlying oversight and reporting
to assure the software is working
as intended. Agree
In
progress
Audit logs have been incorporated into the new
EMR system and will be used in a standardized
fashion. Fall 2015
8
Same as above
It is recommended that appropriate
policies and procedures be in place
for handling of the audit logs. Agree
In
progress
Audit logs have been incorporated into the new
EMR system and will be used in a standardized
fashion. Fall 2015
9
FINDING: General software control observations.
It is recommended the department
assess how they could address
identification of clients and
appropriate limiting of printing and
exporting of clinical records. Agree
In
progress
Clinical records are only printed and/or distributed
as required by coordination of care procedures
with external providers. Historical paper
documentation is being scanned into the EMR. Fall 2015
{END OF REPORT}