Going mobile

The caseworkers at PDG Rehabilitation Services in Glen Burnie, Maryland, used to drive to a central office every morning to pick up their case files, then filled out forms with a pen as they visited clients throughout the day. At the end of each day they would return to the office to enter that data into a centralized computer system, or hand their forms off to someone else to enter.

“That became less and less efficient as the agency grew from 30 clients to more than 300,” recalls Sondra Tranen, executive director of PDG, which provides psychiatric and vocational rehabilitation services.

First, Tranen notes that the process was not HIPAA-compliant, with files in loose folders in caseworkers' cars. Second, there was not an easy way to make good use of caseworkers' time when there were cancellations or no-shows.

But much has changed since PDG introduced handheld devices using wireless technology four years ago. Now the agency's data, case files, and forms can be accessed wirelessly by staff from their handheld devices or laptops using Windows Mobile software.

PDG's managers can schedule the 28 field workers' days ahead of time and send them case files electronically, and documenting visits is more efficient. “The caseworker signs it, the patient signs it, and then it is sent wirelessly and gets queued up for billing,” Tranen explains. “I can batch and send our claims in two minutes. It used to take a whole day for a tech person to round them all up and send them off.”

Wireless devices, such as personal digital assistants (PDAs), and handheld technology are still fairly rare in behavioral healthcare, but they are becoming more common. There's a greater need for mobile solutions because more workers are seeing clients out in the field, says Matt Dorman, CEO of Credible Behavioral Health Software, which helped PDG set up its system. “It just seems logical,” he adds, “but it has taken time for behavioral health players to catch up with the rest of the healthcare field technologically.”

As some payers shift to fee-for-service models, there's also value in getting documentation done the same day, and using handheld devices and laptops in the field makes that easier, explains Dorman.

Dorman also says some of the resistance to learning how to use handhelds comes from older employees less comfortable with technologic change. “A lot of it is cultural, and as we see turnover in personnel, we often see more widespread acceptance,” he says. “And that flows from the top of the organization.” He adds that in surveys done after implementations, his company has found that even those workers who were less tech-friendly initially are pleased. “They would not give up their handhelds,” he says.

In sync with an EMR

North Country Community Mental Health, which serves a six-county area in northern Michigan, has provided caseworkers with laptops for several years. Yet ironically, when the agency started implementing an electronic medical record (EMR) from Netsmart Technologies last year, some of their mobile workers initially saw it as a step backward.

Traditionally, North Country's workers with laptops would type progress notes into a Microsoft Word document, print it when they returned to the office, sign it, and place it in a client's folder, explains Dianne Forster, North Country's information technology director. But with the new EMR software, they couldn't just print their notes; they had to reenter them into the system.

But now, with the vendor's mobile software, their workers can use EMR forms on their laptops in the field, and just synchronize their laptops with the office system when they return. North Country rolled out the mobile solution for testing earlier this year with 10 users and has rolled it out incrementally to 20 more. Fifty caseworkers will eventually use it.

North Country's employees like having access to their caseload on their laptop. “They are dealing with long-term care consumers, people with chronic and persistent mental illness, so they like taking the mental health record with them into the field,” Forster explains. “They can see the progress notes dating back 60 days.”

Forster says the agency researched the possibility of using PDAs or tablet PCs, but they decided users needed a laptop for other tasks such as sending e-mail. “They had to do a lot of typing, and the tablets were better for checking off boxes,” she says. “Plus, I could buy two laptops for what I would have to pay for each tablet.”

Mobile software for crisis workers

The Williamson County Mobile Outreach Team in Georgetown, Texas, had two reasons to get more mobile, explains Director Annie Burwell. “We provide emergency mental health services in the field, and we struggled entering all that data into paper charts,” she says. “Plus, as we respond to calls in the field, we can't carry 3,000 charts in the trunk of our car.”

With a $50,000 mental health transformation grant from the Texas Health Institute, Williamson County has worked with HarrisLogic, Inc., to launch a Web-based database to provide its seven outreach workers and the county's 11 crisis intervention deputies crucial information about the individuals with whom they interact. Having just begun the project, the county team has entered data on about 40 of its 5,000 paper charts.

Burwell says some of the impetus for the project came from mental health consumers. “We heard from them that it was a hassle to keep telling their story multiple times—to first responders, emergency room physicians, and us,” she explains. “This way we have fingertip access to diagnosis, medications, list of providers, emergency contacts, and whether there are weapons in the home.”

That last point is important, Burwell notes. One of the project's key goals is keeping staff safe. “Knowing that this is the Joe Smith with a machete before we knock on the door will make us feel a little bit better,” she says.

Users of the system have Panasonic Toughbook laptops mounted in their cars, allowing them to respond knowing as much as possible about the situation. “If I saw someone last night, and another person is called to that house this morning, in our current paper-based system that data might not be entered” in time for the next encounter, Burwell explains. “But with a live database, that information is entered immediately. We will enter it right in the emergency room or jail or go back out to the car and enter it.”

Challenges

As with any technology project, finding funding can be a challenge. Safe Harbor Behavioral Health in Erie, Pennsylvania, conducted a capital campaign to raise more than $300,000 to pay for its new EMR, says David Rosswog, PhD, Safe Harbor's chief operations officer.

Besides its main outpatient clinic, the agency has 20 satellite sites. Employees have been using tablet PCs in the field, syncing them with their desktop PCs in the office, but Safe Harbor has decided to replace desktop PCs altogether with laptops that have docking stations. Because the EMR is a Web-based, hosted solution from Credible Behavioral Health, Safe Harbor's workers unpack their laptop and plug in at the satellite sites and “it's just like they are sitting in their office,” Dr. Rosswog says.

Even putting aside financial challenges, PDG's Tranen understands why some agencies might be reluctant to make the transition to mobile solutions.

“The transition process really does point out where there are holes in your services in time management and in scheduling,” she says. But for PDG, the change has been a great cost saver. Without it, the agency would need a billing department and more personnel. “We used to have field managers whose sole job was to drive around and make sure people were where they were supposed to be,” Tranen explains. “Now we can see where they are as they send in completed files. They don't have to come into the office all the time.” Because caseworkers cover five counties, the new system saves travel and supply expenses. “I see them only once a week or so,” Tranen says, “which is great.”

David Raths is a freelance writer. Behavioral Healthcare 2008 November;28(11):18-19