California County Information Technology Projects

California County Information Technology Projects
Statewide Information Sharing

Overview, Status, and Lessons Learned

A Mid-Process Review of Placer County’s
Behavioral Health System Implementation of
Netsmart’s AVATAR Products:
California Practice Management (Cal-PM 2005)
Management of Services Organization (MSO 3.1)
Clinicians Work Station (CWS 2004)

Prepared and Presented by:

Placer County
Health & Human Services
Management Information Systems

March 12, 2007
Placer County – Health & Human Services – Management Information Systems
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Table of Contents
Executive Summary.........................................................................................................................4
Introduction......................................................................................................................................4
Project History and Original Project Scope.....................................................................................4
AVATAR Cal-PM.........................................................................................................................12
AVATAR Cal-PM Overview....................................................................................................12
Placer’s Scope of AVATAR Cal-PM Implementation..............................................................14
AVATAR Cal-PM ChallengesIssues in Implementation ........................................................17
AVATAR MSO.............................................................................................................................19
AVATAR MSO Overview........................................................................................................19
Placer’s Scope of AVATAR MSO Implementation..................................................................21
MSO ChallengesIssues in Implementation..............................................................................22
AVATAR CWS.............................................................................................................................24
AVATAR CWS Overview........................................................................................................24
Placer’s Scope of AVATAR CWS Implementation..................................................................26
AVATAR CWS ChallengesIssues in Implementation.............................................................26
Overall Implementation Considerations........................................................................................27
Buy vs. Build.............................................................................................................................27
National and California Based AVATAR User Groups............................................................28
Vendor Participation..................................................................................................................28
What Have We Learned From This Adventure?...........................................................................29
Contact Information.......................................................................................................................31

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Executive Summary
This report presents an annual system review conducted by the Placer County’s Health and
Humans Services, Management Information Systems (HHS-MIS) Department over the life of the
Managed Care Software Project from its inception in 1999 through its current day status as of
March 1, 2007. These annual reviews originally defined and subsequently redefined the scope of
the Managed Care Software Project resulting in updates to the Strategic Plan for HHS-MIS to
meet the evolving requirements of the California Department of Health Services (DHS),
Department of Mental Health (DMH), and Department of Alcohol and Drug Programs (ADP);
consistent with changing state and federal reporting requirements.

Introduction
The goal of this system review document is to share with our counterparts throughout the state of
California, an overview of Placer County’s Managed Care Software Project, the current status,
and most importantly, lessons learned throughout the implementation of AVATAR to meet our
Behavioral Health - System of Care information system requirements. To accomplish this, we
have presented a history of the project with key project milestones, followed by the dynamic
scope of our multi-year project. We have also addressed our partnerships with our vendor
(Netsmart), AVATAR California User Groups, county consortiums, and peer information
sharing amongst counties and other Netsmart customers across the country.

Project History and Original Project Scope
The Placer County Department of Health & Human Services was established in 1995, with a
goal of better serving our clients and the community at-large through integrated services,
universal intake, and centralized administration.

This new County Department merged what was then the Department of Health & Medical
Services, the Welfare Department, and other social services functions into one mega-department,
Health and Human Services. Comprised of nearly 1/3 the County’s workforce, we now have
over 1,100 employees and have a total operating budget of $140 million.

1999 - Project Initiation

In 1999, the Warner Group conducted a comprehensive review of the IT needs within HHS, as a
supplement to the County’s Information Technology Master Plan. The highest business
application need identified by this effort was for a Behavioral Health Managed Care software
system.

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2000 – Project Scope Definition

This Behavioral Health Managed Care Software system would address the needs of a number of
services that were integrated into 2 main Systems of Care -- Adult and Children’s.

These services are listed below:

Adult System of Care Children’s System of Care

• Mental Health Services • Child Protective Services

• Mental Health Billing • Child Welfare Services

• Drug & Alcohol Services • Foster Care Placement

• Drug Court • Crisis Services (Adult & Child)

• In-Home Supportive Services • Juvenile Drug Court

• Public Guardian • Children’s Receiving Home

• Adult Protective Services

• Older Adult Services

• Vocational Rehabilitation

• Assisted Living

The list gives you an example of how we have tried to integrate services, and the challenge we
have to select a software system that will adequately address the data and financial tracking
needs of such a variety of services and functions.

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Additional Services Needing New Information Systems

The Warner Group Study also envisioned that the same software application could eventually be
expanded to include functionality for a number of other, PHYSICAL HEALTH services and
programs, most notably:

• Fee-For-Service Primary Health Managed Care Program,

• Community Clinics, including:
•MIA (Medically Indigent Adult outpatient clinic)
•Women’s Health
•Dental
•Pharmacy

• Children’s Medical Services

• Community Health & Public Health Programs

These programs are currently using a legacy system, rapidly approaching its shelf life. We were
hoping our new application would have the capacity and “hooks” to include these programs.

What Would a New Software Application Do?

We envisioned a new software application to have a number of concurrent capacities to enable us
to be a more robust user of behavioral health client and service information.

Most notably, we were looking for a new application to:

• Permit the collection, storage & tracking of client information, (including outcomes);

• Replace an existing, antiquated mental health billing system with a more
comprehensive, behavioral health practice management information system; and

• Provide management with much needed information regarding client services and
how they are delivered.

2000 – Needs Assessment

In the Spring of 2000, we began an internal needs assessment to determine the specific features
that would be essential for a new software application. This step took most of the Summer of
2000 to complete, so by early Fall, we were ready to develop the Feasibility Study Report (FSR).

We formed focus groups comprised of key HHS staff who could be potential users of the new
information system.

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We organized the focus groups by system function, according to the following categories:
• Direct service clinicians;
• Service authorizations, claims review, payment processing
• Client appointment scheduling/Registration/Demographics
• Client Eligibility
• Financial/Accounts Receivable
• Management

Just to cover all the bases, we tried to make sure that we had a good integrated mix of staff from:
• Behavioral Health Services,
• Physical Health Services,
• Financial and Support Services,
• IT, and
• Management

This effort involved about 70 HHS staff, and served as an excellent “sounding board” for the
folks who will ultimately wind up using the system on a day-to-day basis. We also received a lot
of valuable input regarding the “look and feel” of a new system, in addition to its functionality.

Documenting Data Requirements & Business Processes

Concurrent with the Focus Group discussions, IT Project staff performed a detailed analysis of
behavioral health; addressing the business requirements from various aspects. This included:

• Examining the interface needs of our legacy systems;
• Conducting 135 staff/user interviews;
• Reviewing report & form requirements; and
• Mapping existing business processes.

The kind of analytical steps listed above were essential when we prepared the Feasibility Study
Report (FSR), the Request for Proposal (RFP), and made our selection process much easier,
because we had already done much of our homework.

It actually helped to have two relatively new IT Analysts assigned to this project. They were
able to ask good questions about how and why things work, and became well-grounded in our
business processes very quickly.

We were hoping that the business process mapping experience would also facilitate the
application implementation process, and help us explain how we do business to our potential
software vendor.

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What To Do With The Needs Assessment Information?

By Fall of 2000, we were ready to take all the information and suggestions we had collected over
the summer, and boil them all down to a Feasibility Study Report (FSR).

Our Project Team consisted of a good cross-section of the stakeholder groups:

• Behavioral Health Services,
• Physical Health Services,
• Financial and Support Services,
• IT, and
• Management

We began by looking at all the features the focus groups indicated that were either absolute
necessities or just “nice-to-haves”

Each feature was sorted by functional area, and then checked to make sure we had no duplicates.
These features were also clarified as much as possible.

2001 - Functional Requirements

To make sure we had described each feature correctly, we then returned the list to the focus
group participants.

There were a few items that were either clarified or consolidated from this step.

We ended up with a list of 185 items. Each one was reviewed for its criticality, and assigned a
grade, with a higher weight assigned for those functional requirements that were absolutely
mandatory.

2001 - Feasibility Study Report (FSR)

The FSR is our County’s internal document to ensure that each software request addresses all the
important questions that might come up when selecting a vendor. It also is a way to satisfy
County IT and the CEO’s Office that we have done our homework and that we can justify the
effort.

Placer County has a standardized approach to all FSR’s. County IT has developed guidelines
and a mandatory format to follow, to ensure that all technical questions are addressed in the same
way, in the same sequence.

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In addition to the list of functional requirements, the FSR included the technical specifications,
hardware requirements, and how the new information system will work with our County
Network and other interface needs.

2001 - Request for Proposals (RFP)

From the FSR, it was relatively easy to develop the RFP.

In addition to placing the overall project into perspective, the RFP gave us the opportunity to tell
our story to prospective vendors, giving them an idea of the journey we have traveled to get to
this point, and what we expected of them as traveling companions.

Of course, the list of 185 functional requirements served as the heart of the RFP, and gave the
vendors some concrete standards to respond to.

We worked closely with our County Procurement Services Division to fashion a document that
adhered to all legal and ethical guidelines for fairness, openness, and consistency. We made sure
that we included clear guidance regarding how proposals must be submitted, how they would be
evaluated, the project responsibilities for both the vendor and the County, and formats for cost
summaries and itemized breakdowns, both for one-time and ongoing costs.

Included in the RFP was a series of appendices that gave vendors some added understanding of
the current County environment and what lengths to which we had already gone in documenting
our needs:

Appendices:
• Acronym List
• County Network Diagram
• County Network Access & Security Standards
• Business Process Flowcharts
• System Functional Requirements
• List of Required State & County Reports
• Standard County Software Agreement

Importantly, we included a copy of our standard software contract, as a starting point for vendor
discussions.

Getting the Word Out

During our lengthy discovery period, we had developed a fairly extensive list of potential
vendors. Each of these 60 firms was sent a copy of the RFP, in either hard copy or CD format.
In some cases, the firms requested both.

We also placed the announcement on the County’s Web Site, for broader audience outreach.

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Our timeframe included 3 key dates:

• RFP Release: September 10, 2001
• Bidders’ Conference: October 16, 2001
• Proposal Submittal Deadline: November 13, 2001

What Happened?

Out of the 60 firms contacted, six responded with proposals.

Phase 1 – Determination of Responsiveness
Of the six firms submitting, only 2 complied with the requirements laid out in the RFP. The
Responsiveness Screening was performed by our Procurement Services Division.

Phase 2 – Functional Evaluation
Of these two finalists, both scored a passing grade of 80% on our mandatory requirements list.
The Functional Evaluation was conducted by our HHS MIS Division through a pre-developed
scoring process.

Phase 3 – Evaluation of Responsive Proposals
For the final two proposals, we assembled a 13-member evaluation team comprised of key
stakeholders in each of the functional areas. Also included was a representative from the CEO’s
Office, to provide added perspective.

Once we had all read the proposals, we invited each vendor to provide a day-long demonstration
of their product.

We then assigned a small group of Evaluation Team members to conduct reference checks over
the phone. Evaluation Team members contacted their counterparts in each California County
referenced, getting perspectives from:

• Program staff
• Fiscal and accounting staff
• IT staff

We then reconvened as an entire Team, and shared the results of the reference checks.

Finally, each individual Team member scored each vendor on the prescribed criteria provided in
the RFP.

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2002 - Vendor Selection

Procurement Services scored and totaled the results. Early in February 2002, we made our
selection. The Board of Supervisors approved our request to enter into negotiations with the
selected vendor Creative Socio-Medics (now Netsmart Technologies) on February 26th, 2002.

The three modules of AVATAR selected to meet Placer’s requirements were the California
Practice Management (Cal-PM) module with two additional modules consisting of Managed
Services Organization (MSO), and Clinicians Workstation (CWS).

2002-2003 - Pre Go-Live Activities

Over the course of 15 months, Placer County worked with the vendor to develop a plan for
implementation of the AVATAR products to meet the functional requirements of the contract.
This involved a variety of activities to include software & hardware delivery, training,
configuration, testing, more training, more configuration, and more in depth testing. To meet a
tight implementation schedule, the AVATAR Project Team worked diligently to meet a June 1st,
2003 implementation date successfully.

2003 - AVATAR Go-Live Activities

AVATAR Cal-PM went live on June 1, 2003. With this milestone reached, data was converted
from the existing Yolo Billing system allowing for a single consolidated master client record for
Behavioral Health clients that could be accessed by all modules of the AVATAR product. This
would include Cal-PM, MSO, and eventually CWS, allowing us to realize the immediate benefit
of a master patient record shared by multiple systems that would eventually feed into our HHS
Data Warehouse, SMART, providing accurate statistics of the population we serve.

In the following sections, we will address the current status of implementation for the three
modules we are implementing. In doing so, we will provide an overview of the functionality of
the module and then a description of the scope of implementation for that module followed by
challenges encountered through this phase of implementation.

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AVATAR Cal-PM
To address Placer’s specific implementation of AVATAR Cal-PM, it is helpful to understand the
basic functionality of the AVATAR Cal-PM Module. Below you will find a brief description of
AVATAR Cal-PM as provided by Netsmart Technologies in the section titled, AVATAR Cal-
PM Overview. Additional, information on Netsmart’s products can be found at www.ntst.com.
Following the overview of the AVATAR Cal-PM module are sections addressing Placer’s
specific implementation of this module as well as challenges and issues faced during the
implementation.

AVATAR Cal-PM Overview

Netsmart’s AVATAR California Practice Management (Cal-PM) is the result of a coordinated
effort between Netsmart and several California Counties to meet the dynamic state requirements
of county Mental Health Plans (MHP) and Alcohol and Other Drug (AOD) programs specific to
California Department of Mental Health (DMH) and California Department of Alcohol and Drug
Programs (ADP). Examples of these requirements include Short-Doyle/Medi-Cal claiming, CSI
Reporting, MHSA Reporting, Drug Medi-Cal claiming, and Cal-OMS reporting.

The foundation behind Netsmart’s AVATAR Cal-PM module is the national AVATAR Practice
Management (PM) module which is the result of nearly 30 years of experience in the human
services industry, combined with today’s software development technology. AVATAR is a
comprehensive behavioral healthcare software solution that provides a common gateway to a
suite of robust software modules that are equipped to handle everything from the newest
developments in SQL reporting, automated Methadone dispensing and outcome analysis, to the
traditional workhorses of billing, tracking, scheduling and treatment planning in all types of
behavioral healthcare modalities.

Core functionality of Cal-PM includes the following functional areas:

Client Management
Client admission, account management, leave, discharge, treatment and census data are recorded
on various screens within this module. This module includes a collection of reports that are vital
to the internal business procedures of our clients: Current Unit Census, Bed Availability Report
and tables of active and discharged patients. A historic record is created for each episode of care,
containing all service, diagnosis, treatment and billing information. Bed management, discharge
planning and a number of administrative functions are supported within this module.

California Required EDI
As part of the Client Management module, the California Required EDI menu options contain
the functionality to meet California specific reporting requirements. Enhanced reporting
functionality has been developed to meet the recently modified CSI/DIG reporting requirements,
Cal-OMS reporting requirements, MHSA (FSP, KET, QTR) tracking requirements, and OSHPD

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reporting requirements. Functionality is continually updated to meet the changing requirements
of Medi-Cal, DMH, and ADP.

Practitioner
Staff records are maintained in this module. This is also used as a key cross reference for
ensuring that only eligible providers can render particular services under user defined benefit
plans.

Billing/Billing Reports
This module manages both the billing and accounts receivable functions of the system. It records
all subscriber and plan coverage information, including charge input, bill preparation, payment
posting, client ledger, and electronic claims submission and remittance. Major billing formats
(including HIPAA transaction sets) are supported “off the shelf." This eliminates a need for
third-party billing services. This module provides management and accounting reports to control
the patient revenue/managed care contracts. The reports available include Aged Accounts
Report, Report of Charges, Payment/Adjustment Report, Daily Transaction Report, Active
Receivables and Detail Trial Balance.

Scheduling/Scheduling Reports
The AVATAR Cal-PM scheduling module is tightly integrated with the systems billing
components. Patients are scheduled and as the appointments are kept and services are rendered,
all relevant billing information is sent to the patient’s ledger. Service recording can easily be
distributed to the provider level. Several pre-defined client, staff and facility reports derived from
scheduling data are available in this module.

RADPlus Utilities and System Maintenance (AVATAR System Administrator Utilities)
This module provides three system maintenance areas:
• Client Maintenance provides the tools to delete erroneous clients, program movements
and service entries. Tools are also provided to change a client’s medical records number
and purge the call intake file.
• System Definition provides the tool to build the default system tables for Guarantors,
Benefit Plans, Service Codes, Hospital Bed Files, Referral Sources, Payment and
Adjustment Codes, CPT Codes and Revenue Codes. These tables are used to determine
billing rates and guarantor coverage, and to maintain accurate client treatment histories.
• RADPlus Utilities provide Netsmart clients with control of the system security and
configuration (i.e. menus), as well as full control of content management.

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Placer’s Scope of AVATAR Cal-PM Implementation

Over the course of the next three years from June 2003 through May 2006, AVATAR Cal-PM
was implemented across Behavioral Health’s System of Care. Below is a diagram of the high
level AVATAR Process Flow that is used as a roadmap in implementing AVATAR in new
business areas to track clients, services, programs, and outcomes. A summary of our
implementation is shown in the following sections on the next several pages.

AVATAR Process Flow
CWS 2004 Cal-PM 2005 MSO 3.1
Clinician’s Work Station Practice Management Management of Services Organization

Start

Client Search
Master Patient Index

Admission
Initial CSI /MHSA/Cal-OMS/Other
Req. Data Collection

Financial Eligibility Care Authorization

Assessments /Progress Notes/
Appointment Scheduling Claim Adjudication
Treatment Planning/Other Chart Entry

Client Charge Input /
Workflow Management Review Post Staff Activity Log / Provider Payment Processing
MSO Charge Posting

Diagnosis

State Required Reporting
CSI/MHSA/Cal-OMS and
Other Reporting

837 HIPAA Claiming

835 HIPAA Remittance Processing /
Payment Posting

Client Discharge

Cost Report

End

Diagram: Placer County AVATAR Process Flow

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Placer County Health and Human Services currently uses AVATAR Cal-PM as its primary
Practice Management information system for Behavioral Health. Because Placer County
operates under the Health and Human Services integrated agency model, Placer provides a
complex array of services through a variety of programs under the umbrella of Behavioral
Health; tracking client and service information for 13,144 unique clients last fiscal year.
Additionally, Placer tracks a number of client families for clinical and financial eligibility. In
conjunction with tracking clients by program participation, we have designated an equally
complex array of Guarantors which offer us the ability to claim services rendered out to a variety
of funding sources discussed in more detail in the Guarantor Setup section of this document.

Program Setup
To support the complex requirements of our Behavioral Health Systems of Care, Placer has
developed 194 programs to meet a variety of state tracking, reporting, and claiming
requirements. To summarize our program types, we currently have Programs defined for the
following program areas:

• Central ACCESS Intake
• ACCESS Emergency Response
• Mental Health O/P, Day Tx, Residential
• MHSA - Mental Health Services Act
• Alcohol and Drug Programs
• Adult Protective Services
• In Home Support Services
• Cal-Works
• Child Welfare Services
• Families First
• Family Connections
• Family Preservation
• R.A.F.T. – Rallying Around Families Together
• 26.5 Individual Education Plan
• Managed Care
• Fee For Services
• Organizational Contract Provider – Sierra Family Services

Each of these programs are unique and come with their own reporting requirements both
internally to the county and externally to the state as well as various fiscal intermediaries such as
Medicare and Medi-Cal. It is important to point out that for our business practices; we have
defined a variety of programs to meet a number of Placer County System of Care requirements,
and not only to meet our Medi-Cal (Medicaid) claiming requirements.

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Guarantor/Payor Setup
Similar to our Program setup, Placer has an equally complex array of Guarantors/Payors that are
defined in a client’s Financial Eligibility to designate what services are paid for and by which
Guarantors. We currently have 55 active Guarantors which can be grouped in the following
categories:

• Medicare
• Medi-Cal
• Grants
• Special Funding (MHSA, SB90)
• Private Insurance
• Self-PayFamily Pay
• UMDAP
• General Fund Accounts

Practitioner Setup
Currently, Placer has approximately 1,026 registered Practitioners in AVATAR Cal-PM who
have provided services to approximately 13,114 unique clients last fiscal year. Of those 13,114
active clients, 1,454 clients were referred out for behavioral health services in FY 2005-2006
(soon to be tracked in AVATAR MSO). Of these practitioners, many of them provide services
to clients admitted in multiple programs both independent of each other and concurrently. We
have a large number of practitioners who provide services for Mental Health, Alcohol and Drug,
and Child Welfare programs. With the ability to hold multiple licenses and provide services to
clients in multiple programs, each of our Registered Practitioners require extensive setup in our
Cal-PM system to eventually claim services out to any number of fiscal intermediaries.

Service Code Setup
Placer has opted to use a mix of standard CPT codes and custom service codes to describe,
classify and report both billable and non-billable services performed by practitioners. A
sampling of these service codes is shown by the following categories of Mental Health, Alcohol
and Other Drug, Miscellaneous Services, and Non-Billable Services.

Approved MH CPT Codes:
• (90801) Assessment
• (90802) Interactive Assessment
• (90804) Individual Therapy - 20 to 30 min
• (90862) Medication Support - M.D. Only
• …..

Approved ADP CPT Codes:
• (H0004DF) ODF-Individual Counseling, PPWP
• (H0015DA9) Day Care Rehab (DCR), SACPA, PPWP, CHILD
• (H0019DF9) Perinatal Residential (RES), LT, SACPA
• (H0020DG9) NTP-Methadone, SACPA, PPWP
• …..

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Approved G-Line Payment Codes:
• (GL-0807) Daycare
• (GL-0801) Education
• (GL-0826) Enrichment Activities CalWorks
• (GL-0812) UA Testing
• …..

AVATAR User Base
Currently, Placer has approximately 315 registered and active AVATAR end users that span
several business areas across Health and Human Services (HHS). To put the number of users
into perspective, Placer County HHS has approximately 1191 employees. Of these 1191 HHS
employees, 592 employees work for Adult and Children System of Care, making the percentage
of users at approximately 53% to date. This number will near 100% upon full implementation of
AVATAR MSO and CWS when almost all System of Care staff will be required to do some
portion of their work in AVATAR.

Currently, our end users are represented by staff from the following functional areas: Clerical,
Administrative Support, Accounting, Case Managers, Social Workers, Program Supervisors,
Program Managers, and Directors.

AVATAR Cal-PM ChallengesIssues in Implementation

Challenge #1 – Project Staffing
As the number of end users have increased over the past three and a half years since Placer went
live with AVATAR, MIS Staffing has had to increase as well to continue to move the project
implementation forward and keep up with end user demand, changing state requirements, and
planned implementation activities for AVATAR MSO and CWS.

AVATAR MIS Project Staffing
200 200 200 200 200 200 200
RoleCaledar Year 7 6 5 4 3 2 1 2000
Dedicated MIS Resources
Supervisor (Louie/Larry) 0.25 0.25 0.5 1 1 .75 .25
Project Manager (Eric/Jules) 1 1 0.75 .5 1 1
Implementation Analysts (Pete H./Lonnie) 1 1 1 1 1 1 1 1
Implementation Analysts (Kathy) 1 0.5
Implementation Analysts (Elaine) 0.5
Report Writer Help Desk Analyst (Bal) 1 1 1 1
Info. Technology Techs (Pete K./Candice) 1 0.5 1 1 1
Administrative Technicians (Diana) 0.5
Indirect MIS Support
Network Administrator (Lonnie) 0.1 0.1 0.1 0.1 0.1 0.1
Database Administrator (Larry) 0.1 0.1 0.1 0.1 0.1 0.1
Client PCHelp Desk Admin. (Bob K./John P.) 0.1 0.1 0.1 0.1 0.1 0.1
Total Resource Allocation 6.05 5.05 4.55 4.3 3.3 2.55 2.25 2

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A number of alternatives to minimizing the challengesissues faced with project staffing are
common and frequently used by agencies across the state. These alternatives include: increasing
permanent staff levels to meet the long term goals of the organization; outsource project
management tasks to qualified and experienced professionals; contract with software vendor for
professional services to assist in the implementation of a new system. Each of these alternatives
have their pros and cons.

For Placer, the decision was made to gradually increase MIS staffing over the course of the
project to move the implementation forward as new business areas were brought online with
AVATAR and to meet the business requirements of the growing user base. In addition to
internal resources, professional project management services from the vendor were included in
the contract to assist in the overall implementation of AVATAR.

The down side of this strategy was that there were not sufficient MIS resources allocated to the
project to meet the original requirements and scope of the project. As noted above in the MIS
Project Staffing table, the position of project manager remained vacant from March 2003 through
April 2005 causing unexpected delays in the overall implementation of AVATAR Cal-PM.
Similarly, the vendor rotated multiple project managers through our project to work on the
implementation of specific functionality such as MH Medi-Cal claiming, CSI, Drug Medi-Cal
claiming, and appointment scheduling. At the time, the turn over and subsequent increases in
staffing affected the timeliness of our implementation due to the extended learning curve
required to get up to speed with not only Behavioral Health business processes but the
methodology used for meeting those business process requirements through the implementation
of AVATAR.

Challenge #2 – Project Scope
The system was originally acquired to support 6 major business areas Mental Health Programs,
Alcohol and Other Drug Programs, Community Health, Community Clinics, Pharmacy and
Dental Clinic. A Cyclical implementation was planned to implement four of the products
modules (PM, MSO EMR, and a 3rd party Pharmacy). In 2005, management re-defined the scope
of the project to only include AVATAR implementation in Behavioral Health.

Challenge #3 – Paradigm Shift
The implementation approach presented a paradigm shift to the organization. Business processes
were reengineered to place the system at the front of the processes versus at the end.

Challenge #4 – External Factors (HIPAA)
There were significant changes occurring at Federal and State levels that impacted timelines of
deliverables. HIPAA has required a great deal of resources from both program and MIS areas to
ensure that all requirements are being met by their associated deadlines.

Challenge #5 – Product Readiness (2002-2003)
The product did not meet all of the functional requirements out of the box; many capabilities
were under consideration if not under development by the vendor. Over the course of our
implementation, multiple enhancements were delivered to meet site specific requirements of our
contract.

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AVATAR MSO
To address Placer’s specific implementation of AVATAR MSO, it is helpful to understand the
basic functionality of the AVATAR MSO module. Below you will find a brief description of
AVATAR MSO as provided by Netsmart Technologies in the section titled, AVATAR Cal-PM
Overview. Additional, information on Netsmart’s products can be found at www.ntst.com.
Following the overview of the AVATAR MSO module are sections addressing Placer’s specific
implementation of this module as well as challenges and issues faced during the implementation.

AVATAR MSO Overview

AVATAR Managed Services Organization (MSO) software for Case Management is a system
which serves the specialized needs of states, counties, Managed Care Organizations, specialty
networks, and providers attempting to carefully monitor both at-risk and non-risk contracts. Key
features include:

• Contract tracking (patients, providers and other)
• Service request management
• Authorization tracking
• Case management documentation
• Capitation revenue management
• Costs by CPT codes, physician, patient or period
• Claims adjudication and payment calculations based on negotiated fee schedules
• Multifaceted contract tracking
• Integration with electronic claims
• Payment and/or GL/AP systems
• Enrollment

Member status and eligibility verification are entered into the system to begin the enrollment and
service process. Eligibility for one or more Payor sources are verified and entered into the system
either via automated loads or manual data entry.

Screening
Member requests/needs are assessed and evaluated during the screening process to determine the
appropriate level of care. The user has the ability to create their own assessments using the
RADplus administrators tool set.

Service Authorization
Authorizations are linked to Benefits or Contracted Services in the Contract function.
Authorizations are referenced for claims adjudication/review, calculated in accumulators for
IBNR, and reporting on utilization and profitability.
• Records and tracks authorizations for member services

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• Automatically assigns authorization number
• Selects benefit through link between Member Plan Assignment
• Authorizations and contracts with specific plans

Case Management
This function allows the user to perform case management on an individual member to determine
continued level of care required, document notes, and monitor review dates. Authorization
extensions are also performed in conjunction with transitions of level of care.

Claims Processing
Claims data is received from the provider via electronic file, log data, or paper claims, and are
input into the system for validation and adjudication of service data against authorization data. A
payment recommendation is made by the system for review and approval. Once a batch has been
created, a file is generated to be sent to a GL/AP system for checks production and payment
processing. Explanations of Benefits (EOBs) are also generated to accompany the payment to the
provider.

Reports
• Claims processing inquiry
• Claim appeal inquiry
• Authorization inquiry
• Concurrent review inquiry
• Provider-authorized dollars
• Provider IBNR claims
• Claims paid by provider
• MSO average cost per service per member
• MSO average cost per member per month
• Case manager authorized dollars
• Generate hard copy authorizations
• Provider appealed authorizations
• Current authorizations by provider
• Generate GL/AP report
• Claims paid within 30 days

Maintenance
Through the maintenance functions, the user has the ability to set up contract requirements, plan
definitions, service codes, fee schedules and provider credentialing. Other functions include,
loading of the MEDS MMEF eligibility file, employee registration, member merge and
Authorization Approve/Pend/Denial Rule definitions.

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Placer’s Scope of AVATAR MSO Implementation

Over the past 11 months, Placer County has undergone extensive testing through a variety of
configurations of AVATAR MSO.

In the end, we have determined that we have opted for a higher level configuration of MSO at
the level where the System of Care and Physical Health branch out under HHS. Through this
detailed trial and error period of testing multiple configurations, we have settled on the one
configuration that best meets our business practices and that configuration is summarized below.

Funding Source Setup
A single funding source for System of Care is defined to track authorizations for all Behavioral
Health and Non-Behavioral Health Services tracked within the System of Care. Supplemental to
the System of Care Funding Source Definition, Placer intends to utilize the Budget Tracking
Solution to track Service Authorizations by Budget Account to accomplish the required tracking
of fiscal accounts.

• System of Care (1000)

Additionally, with the implementation of proposed changes to Netsmart, our goal is to link back
to the referring Episode and Program in Cal-PM and the Client’s associated Financial Eligibility
to determine which Guarantors are claimed for services in our step-down billing model for end
of year reconciliation.

Contracting Provider Setup
Placer County HHS has registered 1,026 providers in AVATAR Cal-PM to provide Behavioral
Health services. Of these Providers, approximately 70% would be entered into AVATAR MSO
for use with the Care Authorizations. The remaining 30% of these providers are internal
providers who bill for services rendered through Cal-PM.

Key facts about our Providers in Cal-PM:
• A Provider may be a Primary Care Physician (Physical Health) who provides
Behavioral Health services
• A Provider may provide services to clients in both Physical Health and Mental
Health
• A Provider may perform services in multiple programs across Placer’s system of
care (MH, AOD, and Physical Health)
• A Provider may hold multiple licenses
• A Provider may be contracted under one license type (MFT) at one rate and
different license type (LCSW) at another rate
• A Provider may have multiple reporting numbers depending on Guarantor and
Program
• A Provider may be contracted at a given rate for all services
• A Provider may negotiate an exception rate for a specific client or for all clients
from a point in time forward.
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The above list is key in the accurate mapping of Contracting Providers in MSO to the appropriate
Programs in Cal-PM.

Provider Fee Definition Setup
Provider Fee Definition is set up for all providers registered in AVATAR MSO. Fees are
defined for Providers based on contracted rates which are standard for all providers of a specific
License Type for a Funding Source and Plan. Placer County has opted to use the Fee Override in
Cal-PM so that Fee Definition for services provided in MSO will be the fee posted for the
services to Cal-PM on the client Ledger.

Key Facts - Provider Fees:
• A provider may be registered to multiple Funding Sources in AVATAR MSO.
• A provider may have multiple rates defined for a single Funding Source and CPT
Code based on multiple License Type and Level of Care combinations.

MSO to Cal-PM System Integration Mapping
• MSO Providers are linked to Cal-PM Providers for Medi-Cal Claiming and other State
Reporting.
• Services are linked between the two products.
• Admission/Discharge/Batch Processing to Cal-PM
o This option is not used in Placer County. Our business process dictates that a
client must be admitted to a program in an episode in Cal-PM prior to having a
service authorization created in MSO. As part of this business process,
demographic, CSI, Cal-OMS, and other state required data elements are all
collected and reported out of Cal-PM. Cal-PM is the system of record to meet all
Placer County reporting requirements. The use of this option would not allow us
to collect all required information at the time of admission into a managed care
Episode/Program.

MSO ChallengesIssues in Implementation

Challenge #1:
Provider payments from AVATAR MSO are paid out of specific budget accounts that are
determined by the type of contracting provider, licensure, services provided, adult or
child clients, and the contract details specified in our Performance Accounting System
(PAS) used by the Auditor/Controllers Office, who processes the actual payments
approved through AVATAR MSO. Due to the nature of the business of managing
services to clients to outside network providers, contracts for those providers are
somewhat fluid. Amendments to contracts are made on a regular basis to adjust dollars
allocated to providers through their contracts, especially towards the end of the fiscal
year. To accommodate these changes, we need the ability to manage the authorization of
services by providers to each of clients by the dollar amount allocated to a particular
budget account. This includes the ability to designate a specific budget account on the
Contracting Provider Service Authorizations as well.

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In short, what this entails is extensive development by our vendor for an optimal solution
with full integration between our MSO module and our general ledger accounting system
to exchange data on provider contracts and balances.

As part of our solution, we have opted to develop our own interface rather than having
our vendor work with the Auditor/Controllers vendor to develop the interface. This is not
the optimal solution since our locally developed interface is a one-way interface for
submitting payment authorizations for check disbursement and does not dynamically
manage contract balances to outstanding authorizations.

Issue #1:
AVATAR MSO Providers cannot be mapped to a Cal-PM Staff member and only one
Program due to our current business model of an integrated Health and Human Services
agency. Placer County Providers render services under multiple programs. Integration
between the two modules should be done at the Service Authorization to
Episode/Program to ensure accurate posting of services upon claim adjudication. See
background information in preceding sections for examples of Placer’s complex
Program, Guarantor, and Provider configurations.

Issue #2:
In AVATAR MSO, the Service Authorization screen does not allow for workflow
routing of a Service Authorization from Pending status to Approved. Only MSO Users
with a specific Position Classification should be authorized to Approve Service
Authorizations. For Placer County, it is against policy for a Case Manager to both create
and Approve a Service Authorization. All Service Authorizations must be Approved by a
Supervisor/Manager/Director for services to be legitimately billed against the
Authorization. Functionality similar to that which is contained in the AVATAR CWS
module must be implemented in MSO prior to moving to a completely paperless system.

Issue #3:
Conversion of data from an internally developed MS Access database application has
proven to be difficult. Data structures in the MS Access database have been modified to
an extent that it is no longer viable to attempt a data conversion from the existing system
to AVATAR MSO. This is the down side of developing systems internally.

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AVATAR CWS
To better understand Placer’s plans for implementation of AVATAR CWS, it is helpful to
understand the basic functionality of the AVATAR CWS module. Below you will find a brief
description of AVATAR CWS as provided by Netsmart Technologies in the section titled,
AVATAR CWS Overview. Additional information on Netsmart’s products can be found at
www.ntst.com. Following the overview of the AVATAR CWS module are sections addressing
Placer’s preliminary plans for a phased in implementation of this module as well as some
anticipated challenges and issues that will need to be addressed prior to and throughout the
implementation.

AVATAR CWS Overview

AVATAR Clinician Workstation (CWS), also known as electronic medical record software,
integrates the clinical tools necessary for an interdisciplinary approach to the delivery of health
and human services, including: Treatment/Care Planning, Individual and Group Progress Notes,
Assessments, Nursing Reports, and Workflow Management. In addition, AVATAR CWS
supports electronic views of laboratory results and other interdepartmental data and has optional
features, such as MDS entry/tracking, order entry and pharmacy integration (via third-party
interface).

Treatment/Care Planning
Each facility can create care planning templates tailored to address the unique needs of all target
populations, supporting best practice guidelines. Keyword searches trigger dictionary statements.
The planner steps the clinician through the process from problem definitions and diagnosis to
goals, objectives and interventions. There is also an area to record the staff participating in the
plan. The system provides the capability to include site-specific information, within the
Treatment Plan.

Progress Notes
Progress notes are entered by the clinician for an individual or group. Ambulatory notes are
linked to outstanding services, or the clinician may post a service directly from the entry of the
note. For a group, a template is used to outline the general group content. Then, for each client,
the general outline is individualized.

With the use of a mouse, the individual care plan components (Diagnosis, Problems, Goals,
Interventions and Objectives) are tagged to their associated progress notes, as required by
JCAHO guidelines.

Note Review
The co-signature feature displays the entire history of notes, particular note types, or specialty
area notes for review and signature by authorized personnel. The filing of a note can be general
or within a specialty area, (social work, psychiatry, etc.) making note review simple and more

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direct. The type of note establishes co-signature requirements. Dated addenda are attached to
progress notes directly.
Diagnosis
Diagnosis information is always available and accessed through the use of a DSM-IV look-up
table. This table supports searches by partial description or code. Multiple selections are
supported for all five axes. All DSM-IV codes are cross-walked to ICD-9. Diagnostic
information is linked to the treatment/care planner.

Workflow Notifications
AVATAR CWS has a fully integrated and user-definable Workflow Notification module that
informs a clinician when a progress note is required, an assessment requires approval, a progress
note requires a co-signature or a treatment plan review date is approaching. User defined forms
are linked to these Notifications.

Assessments
AVATAR CWS is delivered with a battery of behavioral and mental health assessments,
including Medical History, Psycho-Social and Nursing evaluations. Additionally, with the
modeling tools included with AVATAR CWS, each facility can create an unlimited number of
assessment forms that reflect facility-specific content.

Form Modeling
Modeling tools are available for constructing dictionaries, screens, multi-page forms, tabs and
drop-down menus. Logic is easily incorporated between fields for the more advanced
requirements. Modeling is automatically mapped to the SQL database for access with industry
standard report writers. Any changes made with these tools are compiled so that they are
unaffected by periodic updates and enhancements released by Netsmart.

Reports
A full reporting suite is available and includes: Missing Patient Flow Sheets, Chart Review,
Nursing Administration Summary, Discharge Report and more. For each staff, a To-Do-List
serves as a reminder of needed progress notes, treatment plan reviews and other required
documentation. Supervisors have access to staff To-Do-Lists.

Treatment Planning Library Versatility
The clinician can create customized treatment planning libraries or use an optional full
complement of Wiley Treatment Planning Libraries, to substantially reduce the preparation time
of individual treatment plans. Library creation is accomplished with a straightforward two-step
process. First, utilize the Treatment Planning Dictionary Maintenance option to create a database
that contains Problems, Problem Definitions, Suggested Diagnoses, Goals, Objectives and
Interventions. Then, use the Treatment Planning Library Definition option to create the user-
defined library that connects each of the components. An option is also included that copies
Problems (with associated diagnoses, definitions, goals, objectives and interventions) from any
library to any user-defined library.

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Summary
AVATAR CWS is designed to support the multi-disciplinary electronic health record. It brings
the electronic medical record to the care giver, supporting an integrated view to critical
information.

Placer’s Scope of AVATAR CWS Implementation

The initial scope of the AVATAR CWS implementation will be identified for a small test group
made up of the MHSA staff and the clinical documentation required by both the Mental Health
Plan and Placer’s MHSA Plan. This small test group will consist of approximately 20 staff
members who will assist in the thorough integration configuration and testing of this module for
the benefit of both program management and IT project staff. Following the successful
implementation of this small test group, we will move forward with a phased implementation for
business areas identified by types of programs defined in AVATAR Cal-PM.

Having already reviewed Yolo and Imperial County’s implementation of AVATAR CWS, we
have begun to formulate our plans for implementing AVATAR CWS in Placer County. As part
of this pre-planning effort we are in process of scheduling several additional site visits to other
AVATAR CWS users within the state to leverage their knowledge and experience with the
product to broaden our exposure of how this module can be implemented and to what extent.

AVATAR CWS ChallengesIssues in Implementation

Challenge #1 – Paradigm Shift
Internal to Placer County, we expect some push back from clinicians in trying to implement
AVATAR CWS because of their current lack of use of a computer system to perform their duties
as a clinician. Current processes for clinicians are primarily paper based processes for updated
client records and charts. Our plan is to introduce AVATAR CWS to small workgroups over a
period of time, providing extensive one-on-one support to ensure the successful transition of to a
paperless system. The first group to be implement will be the MHSA staff since they will have
already begun to enter their own FSF, KET, and QTR forms online for a small targeted
population; allowing them more time to ensure accurate tracking of client information.

Challenge #2 – Continually Evolving System of Care Processes
With our system of care processes continually evolving, we need to have an equally dynamic
information system that can handle changes and at the same time maintain the integrity of the
client’s medical record.

Challenges #3 – Evolving California Department of Mental Health Requirements
Standards currently under development by various standards groups and the state will
undoubtedly affect our implementation of this module.

Over the past several years Netsmart has met all changes in CADDSCal-OMS reporting,
CSIDIG reporting, MHSA reporting, and MMEF file format, to meet state requirements. I am

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confident that they will continue to meet the evolving requirements set forth by the state in
current and future initiatives.

Overall Implementation Considerations
As we have surpassed a major milestone with the implementation of our Practice Management
system for Behavioral Health, it was important to take the time to re-orient by reviewing what
the original project goal was, what we have done to meet that goal, and what still needs to be
accomplished to ensure a complete and successful implementation to meet the organizational
requirements.

Through this project we have learned several things about the overall implementation of a
information system of this size and scope and we have shared some specific issues that we have
had to address along the way. Some of these lessons learned may be specific to Placer County
while others may be more generally applied to any implementation of a health information
system. What we would like to offer are key considerations to address in the selection process of
a system that best meets your requirements and the position we took with regards to these
considerations.

Buy vs. Build

While for the most part, Placer HHS has moved to using Commercial Off-The-Shelf (COTS)
software for our primary health information systems; there are currently a small number of
systems that have been developed internally to meet specific requirements. However, the goal is
to eventually move all client based health information into one of our HIPAA compliant COTS
systems. To accomplish this, Placer needed a system that would meet the business needs as
defined in the functional requirements as well as having the ability to grow and be customized to
meet the business needs of the future that may be specific to only Placer County. Below is a
graphical representation of this spectrum. At one end is the totally custom built system that may
or may not adhere to various standards such as health industry standards, HL7, HIPAA, ANSI,
SQL, and security standards. On the other end of this spectrum is the highly standardized COTS
system that meets all of the aforementioned requirements. To this extreme a standard COTS
system is inflexible and rigid, imposing a single way of doing business, which may not be the
optimal solutions we all require in this dynamic and ever changing healthcare environment.

Highly Configurable/Customizable
Custom Built COTS Systems
COTS System

It is important to determine how import it is to customize an “off-the-shelf” product. Tailor-
made solutions can lead to isolation from other customers and user groups. In this same respect,
customization of a COTS system may benefit other counties through sharing of customized
screens, report development, and other value-added enhancements.

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For Placer, a factor in the decision to select AVATAR was the fact that screens could easily be
developed within the AVATAR to capture site specific information while maintaining the
integrity of the data that the custom data fields relate to; whether it client records, practitioner
records, program records, or any number of other record types contained within AVATAR.

National and California Based AVATAR User Groups

Netsmart sponsors both a California based user group as well as a national user group. While
this may not sound different from what other vendors do, what sets this user group apart from
others is the availability of Netsmart resources at each user group meeting.

For the California AVATAR User Group, Netsmart regularly host this two day user group
conference three times a year at locations determined by the current user group members. This
user group conference consists of Fiscal, Clinical, Administration, and IT staff at all levels of
organizations that currently use AVATAR within California. Additionally, at each meeting,
Netsmart coordinates the required company resources to address training needs, new product
demo requests, new state issues and requirements, future development, and product change
requests from the user group. Over the past several years Netsmart has done this by providing
regular access to their California based Project Managers, California Support Team, and Sales in
addition to regular participation by Netsmart Management from Customer Support and Product
Development. Through this forum, a number of invaluable enhancements have been presented
and incorporated into the various modules of the AVATAR product.

Other national user groups exist that focus on functional areas such as billing, managed care, or
electronic medical records to share different ways of doing business and how the system works
in different environments. At the national level, Netsmart hosts a user conference where
extensive training is provided in all aspects of their products, not only AVATAR. This year will
be the first year Placer participates in this conference.

Vendor Participation

As detailed above, there are a number ways that your vendor can work with you to foster good
communication and evolve with the changing requirements of the environment we work and live
in. It is important for a vendor to actively participate in the process with their customers to
closely understand the requirements that they are being asked to meet. In doing so, a vendor can
respond in a timely manner to development requirements ensuring that all imposed deadlines,
state and federal, will be met.

To ensure that they stay on top of their customers ever-changing requirements, Netsmart takes a
multi-faceted approach to working with their customers and understanding their requirements.
During implementation, a project manager is assigned from Netsmart to work through the details
of the implementation with the customers. Following, implementation Netsmart follows up
regularly on a weekly basis with the county to address change requests, development in progress,

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or issues that may arise during the normal course of business. This includes training on new
enhancements and features delivered through product updates or version upgrades. Before,
during, and after implementation, Netsmart representatives are actively engaged at the state and
federal level ensuring that their product is evolving to meet the changing requirements or their
customers.

All of the above are first hand observations and assessments of Netsmart over the past several
years. The overall relationship between Netsmart customers and Netsmart has evolved from a
vendor-customer relationship to more of a business partner relationship that benefits all involved.

What Have We Learned From This Adventure?

• As in most things, the journey has been just as interesting as the destination.

• Planning and communicating are the top items to ensure you do. For every thing you
don’t plan or communicate, you pay for 10 times over in lost time, wasted resources, and
confused staff.

• Our bureaucracies will always extend the length of even a simple task.

• Language and wording in written form is critical and oftentimes misinterpreted. Think
how others may view your words.

• The end users and stakeholders need to participate in the development process to make
the final product user-friendly and acceptable.

• Other Counties’ pain is your gain -- use their experience to your benefit.

• Every software feature will have relative importance to you -- think about it in
relationship to other features, and assign it a priority.

• Remember that costs can be one-time and on-going -- also stated and hidden.

• Your IT staff already have technical skills. What they need to help the effort be
successful is more familiarity with the details of the “how” and “why” of the operation --
their natural talent to analyze should be used when documenting your business processes
and in the implementation of those business processes in the information system.

• It’s important to have a small, committed group of zealots who will talk with each other
and figure out how to move the process along, regardless of any temporary roadblocks.

• Know what’s going on in the software “biz”. Keep on top of company mergers, failures,
victories, and departures of key staff.

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• Determine how important it is to customize an “off-the-shelf” product -- tailor-made
solutions can also lead to isolation from other customers and user groups.

• We in California have some unique issues and data needs. It’s important that vendors
understand them as much as we do, to make the vendor-customer relationship a true
partnership in finding solutions.

• Make sure to anticipate the inevitable turf battles that come with any joint effort.

• Integration is a word that means different things to different Counties -- figure out what it
means to you and if the vendors you consider would enhance it or impede it.

• Be familiar with the direction of the software industry, so that you take advantage of
forward thinking software -- your vendor decision will be a part of your organization for
years to come.

• If the vendor can’t explain his or her software to you in understandable language, how do
you think it will be received by the “the troops”? This is less of a technical decision than
it is an organizational one.

• Make sure you have the interest, time, and resources to see this thing through.

• Look for the humor and irony -- it’s all around you!

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Contact Information
For additional information on Placer’s implementation of AVATAR for Behavioral Health,
please feel free to contact Eric Duran at:

Eric P. Duran
Sr. Technology Solutions Analyst
SOC & Health Information Systems
Placer County, HHS-MIS
379 Nevada Street
Auburn, CA 95603
Office: 530.886.1809
Email: eduran@placer.ca.gov
Website: www.placer.ca.gov

For additional information on AVATAR or any other general product information, please feel
free to contact Tim Agar at:

Tim Agar
Netsmart Technologies
Office: 916.536.0360
Email: tagar@ntst.com
Website: www.ntst.com

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