Journal of Substance Abuse Treatment 37 (2009) 101 – 109 Brief article Results of a statewide evaluation of “paperwork burden” in addiction treatment Deni Carise, (Ph.D.) a,b,⁎, Meghan Love, (B.S.) a , Julia Zur, (B.A.) a , A. Thomas McLellan, (Ph.D.) a,b , Jack Kemp, (M.S.) a,c a Treatment Research Institute, 600 Public Ledger Building, 150 South Independence Mall West, Philadelphia, PA 19106-3475, USA b University of Pennsylvania, Center for Studies of Addiction, Philadelphia, PA 19104, USA c Delaware Division of Substance Abuse and Mental Health, New Castle, DE 19720, USA Received 12 September 2008; accepted 6 October 2008 Abstract This article chronicles three steps taken by research, clinical, and state staff toward assessing, evaluating, and streamlining clinical and administrative paperwork at all public outpatient addiction treatment programs in one state. The first step was an accounting of all paperwork requirements at each program. The second step included the development of time estimates for the paperwork requirements; synthesis of information across sites; providing written evaluation of the need, utility, and redundancy of all forms (paperwork) collected; and suggestions for eliminating unused or unnecessary data collection and streamlining the remaining data collection. Thirdly, the state agency hosted a meeting with the state staff, researchers, and staff from all programs and agencies with state-funded contracts and took action. Paperwork reductions over the course of a 6-month outpatient treatment episode were estimated at 4 to 6 hours, with most of the time burden being eliminated from the intake process. © 2009 Elsevier Inc. All rights reserved. Keywords: Addiction treatment; Clinical information systems; Electronic records; Evaluation; Paperwork 1. Introduction Substance abuse treatment providers are inundated with reporting requirements (McLellan, Kleber, & Carise, 2003). The burden of excessive paperwork in the health care field is well documented, and many studies have demonstrated its negative impact on the well-being of health care professionals. For example, a study of professional psychologists found that increased administrative and paperwork hours were associated with greater emotional exhaustion and burnout (Rupert & Morgan, 2005). Other studies have found that paperwork was among the greatest stressors (Rupert & Baird, 2004) and challenges (Kantorowski, 1992) reported among professionals in the mental health field. Many studies have also documented the degree to which paperwork is associated with job dissatisfaction. In a study of mental health professionals, 50% of those surveyed reported ⁎ Corresponding author. Tel.: +215 399 0980x102; fax: +215 399 0987. E-mail address: dcarise@tresearch.org (D. Carise). 0740-5472/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2008.10.009 dissatisfaction with the amount of time they spent on paperwork. When asked to choose from a list of job responsibilities, mental health nurses identified paperwork as being the one item with which they were most dissatisfied (Robinson, Murrells, & Smith, 2005). Cypres, Landsberg, and Spellmann (1997) also surveyed mental health professionals and found that paperwork was one of the greatest job complaints because counselors reporting it compromised the amount of time they were able to spend with their clients. Paperwork burden problems are not unique to the nursing or mental health fields. Counselors in the substance abuse treatment field frequently report being inundated by documentation requirements. The burden of these requirements was a pervasive complaint reported by a sample of 175 substance abuse treatment programs in a telephone survey on information collected in the course of their day-to-day work. Numerous programs cited paperwork burdens of 4 hours or more at patient admission simply to collect data required by state agencies and multiple managed care organizations (McLellan et al., 2003). 102 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 In other studies, 38% of substance abuse treatment case managers reported spending more than 20% of their work week completing paperwork (Brindis & Theidon, 1997), and McDaniel, Spieglman, and Beattie (2006) also documented the dissatisfaction substance abuse treatment providers reported with the increased paperwork requirements resulting from managed care. Substance abuse treatment programs collect data for accreditation, managed care, research, and outcomes reporting purposes. State offices, accrediting agencies, managed care organizations, and other regulatory agencies (including but not limited to drug courts, parole, welfare, and child welfare) each demand collection of specific information or data. Perhaps most important in this regard is that much of this data collection is considered nothing more than “paperwork” by the counselors and other personnel within the programs that collect it because the information collected in most of these forms is not inherently useful for clinical care decisions. Adding to the burden and the resentment caused by these multiple reporting requirements is the frustrating and often substantial overlap in the nature of the information requested by the various agencies and organizations. The focus of our original work with the Delaware Division of Substance Abuse and Mental Health (DSAMH) was to assist with the design and evaluation of a new statewide, performance-based contracting (PBC) system. All outpatient abstinence-oriented adult substance abuse treatment programs were required to provide treatment services at a minimum of 90% capacity. In addition, they were required to collect standard admission data on all clients and to rapidly report client attendance data during treatment as well as type and date of discharge. The data reported were audited for accuracy and capacity, and rates of attendance became central determinants of reimbursement for the programs. As a result of this project, those programs that were able to retain clients in active participation longer received performance incentives, whereas programs that were not able to retain clients did not receive these incentives (McLellan, Kemp, Brooks, & Carise, 2008). This contracting effort, although purposely quite simple, led to significant increases in client census and in lengths of stay in the participating programs—as well as increased income. In addition to the measures associated with PBC, DSAMH was interested in initiating a pilot project with the assistance of the Treatment Research Institute (TRI) to introduce the collection of key clinical data items by counselors in face-to-face treatment sessions during the course of outpatient treatment. The collection of these additional client status measures on all clients at multiple times over the course of treatment (called concurrent recovery monitoring [CRM]; McLellan, McKay, Forman, Cacciola, & Kemp, 2005) threatened to impose still more data collection on the already burdened clinical staff at these treatment programs. Although clinical staff were not conceptually against CRM—and indeed, even endorsed it —there was understandable frustration regarding how this additional data collection of client-level behavioral measures at each individual session would actually be accommodated. Acknowledging that these clinically meaningful activities would also result in additional data collection and reporting, TRI conducted a “Paperwork Burden” assessment to determine the nature, volume, and extent of overlap among the multiple data collection demands currently affecting all state-funded outpatient substance abuse treatment programs. If it were not possible to eliminate at least the same amount of data collection, time and effort required for the proposed CRM procedure, it seemed unfair to ask the programs to participate in the CRM study. Therefore, this article describes this systematic evaluation of the data collection and reporting requirements at these treatment programs and reports the administrative changes (to decrease paperwork) resulting from this evaluation. 2. Methods The director of the research team had several years of prior experience working with the State Director and indirectly with the treatment programs. The investigator of this project met with the State Director and asked if he would be interested in piloting the Paperwork Burden study and if he felt this would be of interest to the state-funded outpatient, substance abuse treatment programs. With interest and approval from the State Director, during a regularly scheduled quarterly meeting with the providers and state director, the investigator described the Paperwork Burden evaluation (and the larger study) to the providers (primarily program directors and supervisors). The providers were enthusiastic and agreed to participate. To implement the paperwork reduction assessment, 2 senior TRI research staff traveled to each of the 11 state-funded, adult outpatient substance abuse treatment programs for a half-day meeting (approximately 5 hours) with various staff members. The purpose of this in-person site meeting was to assemble a complete inventory of all data collection instruments and forms. This paperwork assessment was not confined to the paperwork required by the state drug and alcohol agency because each of these 11 programs had client referral arrangements with other state agencies (e.g., Probation/Parole, Child Protective Services, and so forth), managed care organizations, and private insurance carriers. In addition, programs received referrals from managed care organizations that also required various information and reports. Finally, the documentation also included data collection requirements of nongovernmental organizations such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The study was approved by the Institutional Review Boards at both Treatment Research Institute and the Delaware Health and Social Services. Because participating in the Paperwork Burden review was completely voluntary for staff, did not involve patients, and collected no identifying D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 information from staff, informed consent was not required. The Paperwork Burden assessment was conceptually very simple but procedurally quite demanding. It required 6 months to complete and initially consisted of the 5-hour inperson visits to each site by two senior TRI research staff who met with the program directors, administrative and clinical staffs to compile every form and piece of information required by any of the agencies described above. The evaluation included all forms required by any of the above agencies or organizations on clients at admission, during the course of treatment, at discharge/transfer, and at follow-up. This part of the evaluation resulted in a spreadsheet identifying all forms collected by program. These spreadsheets were sent via email to each site where they were inspected by participating site staff followed by several additional interactions generally by phone but occasionally in person with staff to assure the accuracy and completeness of our reports. In this regard, staff at the programs often had mixed opinions about which data collection activities were required, by whom, and for which clients. It was regularly the case that clinical staff at a program (who actually collect the data) would say that, “we use the ‘XYZ’ form, it's required”; however, their supervisor would say, “we don't use the ‘XYZ’ form, it hasn't been required for several years” or vice-versa. In these cases, we entered into our spreadsheets all those forms that were actually used in data collection by at least one staff member but recorded all the comments from both supervisors and direct care staff. We believe this method provided the most realistic appraisal of the actual paperwork collected. We provided these final reports to the State Substance Abuse Director, other DSAMH staff, and to all treatment programs. The State Director, treatment providers, and research staff met as a group once more when the Director dedicated 3 hours of their regularly scheduled quarterly meeting to reviewing the results of these findings deciding on a course of action. 2.1. Description of treatment programs All outpatient substance abuse treatment programs that had contracts with DSAMH (n = 11) participated in the paperwork reduction assessment project. We used the Addiction Treatment Inventory (ATI) to measure program characteristics. The ATI is a semistructured interview completed with treatment program directors. It is designed to provide standard information on the staffing profile, treatment orientation, organizational structure, financing, and services delivered in all modalities of addiction treatment programs (Carise, McLellan, & Gifford, 2000). 2.2. Program organization The 11 outpatient programs in this review were actually run by four “parent” agencies. Nonetheless, results reported here refer to the 11 treatment programs because even those programs within parent agencies routinely differ in their characteristics. 103 2.3. Frequency of group and individual counseling In 8 of the 11 sites (73%), clients attended group treatment twice a week and had individual counseling sessions about once a month. At the remaining 3 sites (27%), clients attended group once per week and saw a counselor on an individual basis twice a month. 2.4. Intake scheduling Six of the sites (55%) accepted only scheduled clients for admissions, whereas two sites (18%) had no scheduled appointments—all admissions completed via “walk-in” procedures. The remaining three sites (27%) accepted both walk-in and scheduled clients. 2.5. Accreditation Of the 11 sites, 6 (55%), were accredited by the JCAHO, and 2 sites (18%) were in the process of obtaining JCAHO accreditation. Five sites (45%) reported being accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). Four sites (36%) were accredited by both CARF and JCAHO. 3. Results 3.1. Organizing forms All sites used the following three organizing forms— although it later emerged that only one form, the Client Service Record, was required by the state. 3.1.1. Intake log/schedule book All sites had a log or sign-in book to document who entered care and at what date. Time required is 1 to 2 minutes per client. 3.1.2. Client service record Documentation of services provided to all clients was required by DSAMH's licensing standards. This form documented the dates and duration of services provided such as preadmission/evaluation meetings, individual/ family, mental health/psychiatric, group sessions, and case management session for an individual client through their course of treatment. All sites used this state-required form. Time required is 3 to 5 minutes per contact per session. 3.1.3. Checklist of Required Forms All sites had one or more forms to assure inclusion of all required forms in each client chart. According to state authorities, these forms were intended to assist staff as a reminder of items that needed clinical review or updating. However, some sites reported completing this form at discharge suggesting that they may be using it simply as 104 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 an administrative checklist. Time required is 10 to 20 minutes total when done throughout treatment; however, some sites reported the form took 60 minutes when completed at or after discharge. 3.1.3.1. Organizing forms suggestions. The intake log/ schedule book carries only a minimal burden of 1 to 2 minutes per client, and the Client Services Record (the only required document in this category) takes only 3 to 5 minutes per contact or session)—no changes are suggested. The problematic form was the Checklist of Required Forms. Although it is often useful for agencies to have a checklist to make certain all required forms have been completed, filling out the Checklist after the patient has left treatment diminishes its usefulness and presents a significant time burden to the counselor. As a result, we strongly recommended that if sites wanted to continue using the Checklist of Required Forms for their own assurance purposes, that they collect this information during the course of treatment, not at discharge. With that provision, the average amount of time taken for organizing forms could go from an average of 14 to 67 minutes down to 14 to 27 minutes, decreasing the paperwork burden between 0 and 40 minutes depending upon the current practice at the site (see also Table 1). 3.2. Client administrative forms at intake The great majority of client data collection for all programs surveyed was completed at intake/admission. Of the 11 sites, 6 reported that intake data collection requirements could be completed in one session (approximately 2–3 hours), whereas 5 of 11 sites reported that intake requirements could take two to three separate sessions and up to 7 hours. Table 1 Time reductions by type of paperwork Paperwork burden prior to study Range (minutes) Intake/Admission forms (3 components) 1. Organizing forms Intake log/schedule book Client service record Checklist of Required Forms Total organizing forms 2. Client administrative forms Client rights, confidentiality, HIPAA Consent and release of information Program description and rules Total client administrative forms 3. Intake assessment forms CRF ASI ASAM PPC-2R SOGS MAST Interpretive summary Assessment summary Other info for JCAHO Total intake assessment forms Intake paperwork tally/reduction Recommend change Paperwork burden after study Burden reduction Range (minutes) Range (Minutes) 1–2 3–5 10–60 14–67 No No Do during 1–2 3–5 10–20 14–27 0 0 0–40 0–40 10–20 5–10 5 20–35 No Combine Combine 8–18 4–7 3–5 15–30 2–2 1–3 2–0 5–5 10–15 45–60 30 10 7–10 30–45 30–45 15–30 177–245 211–347 No No Yes Screener Yes Yes Yes No 10–15 45–60 0 2–10 0 0 0 10–20 67–105 96–162 0 0 30 8–0 7–10 30–45 30–45 5–10 110–140 115–185 During treatment and treatment planning forms ASI update every 3 months ASAM update every 3 months Subtotal Treatment paperwork tally/reduction (6-month treatment episode) 30–45 10–15 40–60 80–120 Yes Yes 0 0 0 0 30–45 10–15 40–60 80–120 Discharge forms CRF ASI at discharge ASAM at discharge Discharge paperwork tally/reduction 5–10 30–45 10–20 45–75 No Yes Yes 5–10 0 0 5–10 0 30–45 10–20 40–65 101–172 1.7–2.9 235–370 3.9–6.2 Overall paperwork reductions Total paperwork reduction (in minutes) Total paperwork reduction (in hours) 336–542 5.6–9.0 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 The administrative portion of the intake paperwork requirements included (a) client protection and rights forms (including confidentiality and protection of information procedures), (b) consent for treatment and release of information forms, and (c) documents describing the program, its rules, fee agreement, and grievance policy. 3.2.1. Client protection and rights, statement of confidentiality, and HIPAA These forms are required by DSAMH licensing standards, and all sites had forms related to these issues; however, there was significant variability across sites in the application of these forms. Each site was missing some of the components of Health Insurance Portability and Accountability Act (HIPAA) requirements, including specific information on expiration dates of consents; a statement of the individual's right to revoke his or her authorization and how to do so; whether treatment, payment, enrollment, or eligibility of benefits could be conditioned on authorization; or a statement of the potential risk that personal health information may be redisclosed by the recipient. Time required is 10 to 20 minutes. 3.2.2. Consent and release of information forms All sites had consent forms. All but 1 site had emergency contact releases, 6 combined this information with other forms, and 4 had separate forms. All sites had forms for the DSAMH requirements of (a) for DSAMH to let the treatment program know if a client is covered by state funding and (b) for treatment programs to bill DSAMH for covered services provided by the treatment program. Of the 11 sites, 6 had two separate forms for this purpose, whereas the other 5 sites combined the forms into a single consent. Combined release forms and to/from releases are accepted as long as the consent is completed correctly according to Federal Law requirements (SAMHSA, 2004). Time required is 5 to 10 minutes. 3.2.3. Documents on program descriptions and rules Of the 11 sites, 9 (82%) had program descriptions, rules, and schedules on separate forms—each of which required patient signatures. These were local forms not required by State licensing, but they did inform clients about relevant aspects of the programs' operations. Of the 11 sites, 7 (64%) had a Client Handbook that included all clientrelevant forms and schedules. Of the 11 sites, 9 (81%) had formal grievance policies, with 4 sites (36%) having included this information in their HIPAA forms. There was some confusion regarding a “Client Choice” document designed to ensure notification to the client of alternate treatment options. Six sites (55%) thought it was required and included it, whereas 5 others did not. We confirmed for sites that this form was not required, and several immediately stopped using it. There were 2 sites (18%) that continued to use this form because they felt that it was important for clients to be aware of other treatment options. All sites had multiple fee agreement forms including a Fee 105 Collection Sheet, Sliding Scale Fee Guideline form, and Fee Schedule. Time required is 5 minutes. 3.2.3.1. Client administrative forms suggestions. We developed a HIPAA form that could be used by all sites that fully covered all requirements for HIPAA authorization. We also recommended that all programs combine their Consent and Information Release forms into a single form that would service all state agencies and that could accommodate sending of information in both directions between the state agencies and the programs. So, for example, whereas most sites currently had one form to allow the treating agency to send intake information to DSAMH as required and an additional form for clients to allow DSAMH to send information to the treating agency to identify if the client was covered by the state for the treatment services provided, they now use a single form. We also recommended that the four sites that did not provide a Client Handbook begin doing so because this is a way to provide relevant information in one document. Finally, we recommended the consolidation of the Fee Collection Sheet, Sliding Scale Fee Guideline form, and the Fee Schedule form into one form, thereby reducing the number of forms to review with the client. Program staff estimated that completion of Client Administrative Intake Forms averaged 20 to 35 minutes per client. By following our recommendations, the time to complete this category of paperwork would be reduced to 15 to 30 minutes per client, decreasing paperwork burden by 5 minutes. 3.3. Intake assessment forms Perhaps the most time-consuming forms collected were those for client assessment. All sites were required to collect data on the State's Consumer Reporting Form (CRF). In addition, at admission and again at various times during the client's treatment, administration of the Addiction Severity Index (ASI) and the American Society of Addiction Medicine (ASAM) client placement criteria were required. In addition to these, sites also collected various other assessments or biopsychosocial instruments either of local interest or required by various managed care organizations. Some of these included the Michigan Alcoholism Screening Test (MAST), the South Oaks Gambling Screen (SOGS), and several nonstandardized forms. 3.3.1. Delaware's CRF The CRF was the core instrument required by DSAMH to begin the process of registering the client as having entered the treatment system and to collect basic client level data, much of which is required by the Substance Abuse Prevention and Treatment Block Grant. Time required is 10 to 15 minutes. 3.3.2. Addiction Severity Index The State required the ASI (McLellan et al., 1992) be completed upon intake for all clients. Most of these sites 106 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 (10/11) used the Drug Evaluation Network System's computer-assisted version of the ASI. The DENS version of the ASI requires appreciably less time than the standard paper-and-pencil interview and also produces a narrative summary of the information and the beginnings of a basic treatment plan (Carise, Gurel, Kendig, & McLellan, 2002). Time required is 45 to 60 minutes. 3.3.3. The ASAM Patient Placement Criteria The ASAM Patient Placement Criteria (PPC) is a set of guidelines used for placement, continued stay, and discharge of clients with alcohol and other drug problems into five broad levels of care from Early Intervention to Medically Managed Inpatient Treatment to aftercare (ASAM, 2006; http://www.asam.org/ppc/ppc2.htm). Time required is 30 minutes if client is not transferring to a higher level of care. 3.3.4. Additional forms 3.3.4.1. South Oaks Gambling Screen. The SOGS is a brief self-report questionnaire designed to detect gambling problems (Lesieur & Blume, 1987; Stinchfield, 2002) that was used by all treatment programs, as it had been required by DSAMH several years earlier. Time required is 10 minutes. 3.3.4.2. Michigan Alcoholism Screening Test. This is a brief self-report questionnaire designed to detect alcoholism (Selzer, 1971). It is widely used in clinical and research settings. The 24 scored items assess symptoms and consequences of alcohol abuse. Of the 11 sites, 4 reported using the MAST to fulfill requirements by the state or its licensing board. Time required is 7 to 10 minutes to administer and score. 3.3.4.3. The interpretive summary. Five sites wrote a specific “interpretive summary,” essentially a clinical impression of the data collected at admission assessment. Time required is 30 to 45 minutes. 3.3.4.4. The assessment summary. Of the 11 sites, 10 were also doing an assessment summary of the ASI and ASAM data. Time required is 30 to 45 minutes. 3.3.4.5. Miscellaneous forms. There were also items collected on the following topics: Spirituality, Leisure time activities, HIV/Risk Assessment, Nutritional Screening, and Quality of Life information. Much of this appeared to be clinically important as well as necessary for JCAHO requirements. Time required is 15 to 30 minutes total. 3.3.4.6. Intake assessment suggestions 3.3.4.6.1. Consumer Reporting Form and Addiction Severity Index. We recommended no changes to Delaware's State Intake form (CRF), recognizing that a change in this form would necessitate a complete overhaul of the state- administered computerized data collection system. In addition, we recommended no overall changes to the ASI form because this too would leave 10 of the 11 sites without computerized capability for collecting this data. 3.3.4.6.2. American Society of Addiction Medicine. Because the programs in this evaluation were outpatient programs and there is almost never a challenge on treatment need for this level of service, the ASAM criteria may not be essential, particularly if traditional outpatient care was determined to be the level of care needed. However, it was acknowledged that the ASAM criteria might be necessary for those patients seeking transfer to a higher level of care. DSAMH agreed to the use of ASAM criteria only for higher levels of care, and this saved approximately 30 minutes on intake paperwork. 3.3.4.6.3. South Oaks Gambling Screen. The requirement to complete the SOGS was clinically sensible but not necessary for all clients. A two-question screener (taking no more than 1–2 minutes to administer) was designed to identify patients who had never gambled. Only a positive screen to these two questions led to administration of the full SOGS. Therefore, if the client had never gambled (and a significant proportion had not), the SOGS was not administered. This decision rule led to a time savings of approximately 8 minutes. 3.3.4.6.4. Michigan Alcoholism Screening Test. Although the MAST is a useful clinical tool, the evaluation uncovered that it was not required by DSAMH (as programs had thought) and that it did not collect substantially different information than was already being collected at intake. As a result, treatment programs decided to eliminate it from the standard data collection, resulting in a savings of 7 to 10 minutes. 3.3.4.7. Assessment and interpretive summaries. Most sites were completing an Assessment Summary and an “Interpretive Summary.” We checked to see if DSAMH preferred a particular style or content for client admission interview and summary (other than requiring the ASI and CRF) and found that these two documents were not required and that all methods of other assessment and intake summaries were acceptable. Because more than half of the sites were interested in JCAHO accreditation and because JCAHO required a narrative intake summary, we suggested that sites use the automated DENS-ASI summary, which contains all relevant information in a computer generated, narrative report and has been used successfully in many JCAHO accredited sites (10/11 sites were using the DENS ASI software). DSAMH agreed to accept the DENS-ASI narrative relieving the programs of the “Interpretive Summary” and the “Assessment Summary,” and resulted in a total time savings of 60 to 90 minutes (30–45 minutes were typically needed to write each summary). 3.3.4.8. Miscellaneous forms. As noted above, many programs were using their own forms for additional questions about leisure time activities, quality of life, pain assessments, D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 family, nutritional, and HIV assessment. Because the forms were used randomly by different sites and counselors reported that they served a specific purpose, we did not recommend deletions here. Instead, we recommended that programs retain those forms they found useful but produce a common battery of these forms in standard formats so that they were all collecting the information in the same way and consolidate these questions into one form. These procedures resulted in a 5- to 10-minute decrease in paperwork. In summary, prior to the implementation of our suggestions, completing the intake assessment forms took from just under 3 hours to just over 4 hours (177–245 minutes) to complete (depending upon site procedures and inclusions). Per our suggestions, the elimination of the ASAM for those entering traditional outpatient care, the MAST, and the Interpretative and Assessment summaries; the adoption of a SOGS screener; and the consolidation of miscellaneous forms resulted in a reduction of 1.8 to 2.3 hours (110–140 minutes) in paperwork. Intake assessment now takes on average 1.1 to 1 3/4 hours (67–105 minutes) to complete. See Table 1 for a tabular representation of the findings. 3.4. During treatment documentation Treatment planning and treatment documentation paperwork was much more variable across the 11 programs, and there were fewer requirements by the state and less standardization. Most treatment programs reported that an administration of the ASI was required every 3 months throughout the course of treatment. This was actually not the case, but it was essentially a widespread misunderstanding causing most programs to spend 30 to 45 minutes per client, every 3 months completing an updated ASI. Similarly, programs believed the ASAM client placement summaries were also required for all clients every 3 months, although DSAMH reported that this requirement had been eliminated some time prior to this evaluation. ASAM summaries continued to be required only if the client was moving to a different level of care. Time required for repeated ASAM placement criteria was approximately 10 to 15 minutes per client—repeated every 3 months. 3.4.1. During treatment documentation suggestions Readministering the complete ASI every 90 days for clinical purposes during the course of treatment is not necessary. In addition, as indicated previously, reevaluating the ASAM placement criteria may only be desirable in the case of client transfers to more intensive levels of care. Thus, we recommend that DSAMH clarify that they had indeed previously eliminated both the ASI and ASAM administration requirements for during-treatment reporting and that a more streamlined client “checkup” form be pilot tested to achieve the same purposes. Based upon this recommendation, DSAMH reiterated that ASI and ASAM updates were not required during treatment with one exception—ASAM summaries continue to be required to refer a client in 107 outpatient treatment to a DSAMH-funded residential program. This resulted in a net time savings of 40 to 60 minutes every 3 months or 1 1/4 to 2 hours over the course of a 6-month treatment episode. 3.5. Discharge paperwork 3.5.1. Delaware's CRF at discharge A second CRF form is required to be completed and sent to DSAMH to document the date and nature of the client's discharge from the treatment system. Time required is 5 to 10 minutes. 3.5.2. Addiction Severity Index All programs were required to collect a final ASI at the time of discharge on all clients. Time required is 30 to 40 minutes per client. 3.5.3. American Society of Addiction Medicine Patient Placement Criteria All programs were required to collect a final ASAM PPC form at the time of discharge. Time required is 10 to 20 minutes per client. 3.5.3.1. Discharge paperwork suggestions. Based on the reasoning noted in Section 3.4 regarding the use of the ASI and ASAM PPC-2R during treatment, DSAMH eliminated the collection of the ASI and ASAM PPC at discharge as well. This led to a reduction of an additional 40 to 60 minutes of paperwork at discharge while still obtaining all of the information that they were actually using from the state CRF form that is readministered at discharge. 3.6. Follow-up meeting/action plan As noted above in Methods, after providing the final reports to all participants, the State Director, treatment providers, and research staff met as a group once more when the Director dedicated 3 hours of their regularly scheduled quarterly meeting to reviewing the results of these findings deciding on a course of action. Representatives of all treatment programs, the researchers involved, the State Substance Abuse Director, and other DSAMH staff, including representatives from the licensing unit, were in attendance. This meeting began with a presentation of the findings from the paperwork assessment that highlighted each form, the amount of time taken to complete the form, the number of sites completing the form, and whether they believed the form was required. For each form, the group entered into discussion regarding the use of the data, the State Director discussed reasons for requiring the form (if applicable), the research staff presented reasons for and against the collection of the data (i.e., we were against the collection of the ASI and ASAM every 90 days and provided both a scientific and practical basis for our reasoning), the provider staff discussed their experience with collecting the information 108 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 and the group, led by the State Director, came to a decision regarding whether the form/data collection was valuable clinically or administratively. Interestingly, one of the most compelling findings was the extent of misunderstanding regarding what was required by the various funding and regulatory agencies (e.g., DSAMH, criminal justice and child protective agencies, JCAHO, and CARF) and the rationale for why information was collected. In general, many forms that programs believed to be required were no longer used nor required. Moreover, some of the forms that were required did not actually result in administrative action or decision support and thus were not really useful to those who were requesting them. Based upon the findings gathered in the evaluation, most of the recommendations for elimination and consolidation of reporting were accepted and put into place immediately. In summary, data collection time was reduced by approximately 2 to 3 hours per patient at intake/admission, approximately 1 to 2 hours per patient during the course of an average 6 month outpatient treatment episode, and approximately 40 to 60 minutes at treatment discharge. A reasonable estimate of total time saved per patient over the course of a 6-month treatment episode is 4 to 6 hours. 4. Discussion We believe the Paperwork Burden Assessment led to a more streamlined and efficient data collection process that importantly has not eliminated any useful information. Moreover, this effort was seen as a good faith effort to acknowledge and address the legitimate time constraints on these programs—paving the way for a collaborative effort to improve clinically and administratively relevant data collection for improved accountability. We believe the implications are significant for other administrators and public authorities to give them a tangible estimate of the data collection burden that affects so many programs as well as one reasonable way to add the collection of new, important variables. That is, if new measures or data collection items are to be added, the value and necessity of collection of older items or measures should be reviewed. Whenever possible, do not add to data collection without taking away something that is already being collected. Equally important, do not collect data that are not being used, and show providers the utility and value of the data by providing results back to those you are asking to collect the data. Once clinical staff see the use of the data and maybe even begin to use it clinically, their investment in collecting accurate and timely data will increase. It is likely that the history of this group (providers, researchers, and the State Director) working together was an important factor in the success of this meeting; however, the importance of the willingness and openness of the State Director in discussing the data collection and making changes to the current requirements cannot be underestimated. This activity simply could not have been successful without the State Director's willingness to make changes, to hear the treatment providers concerns and suggestions, and to trust the research group's scientific opinions. The level of interest in program improvement can also be seen by the participation of two treatment programs involved in the Network for the Improvement of Addiction Treatment projects as well as the State's participation in the Robert Wood Johnson Foundation's Advancing Recovery initiative. Both of these programs have goals of improving systems of care that are consistent with this project. The Paperwork Burden assessment was an important and valuable activity for the state, its substance abuse treatment providers, and the participating researchers. It was rewarding to see such a significant impact from such a basic endeavor. These activities positively affected the relationship between the state agency and the treatment providers and between the treatment providers and the researchers and led to a number of basic gains for all involved. First, it created a stronger collaborative atmosphere for all concerned—the state agency, the state-funded treatment providers, and the researchers working within the state. Providers saw that both research and state agency staffs were listening to them and were responding to their concerns. In addition to increasing collaboration and goodwill between the parties, these activities generated a new way of thinking about paperwork and data collection within the state. It became clear that that data should only be collected if it could produce meaningful information. The process has reoriented thinking on the part of programs and DSAMH leading to a better understanding of the need to have a specific reason for collecting each form and each piece of data. The state is more cognizant of only requiring those items that they believe are essential for client care or those they will actually use for some specific purpose in the future. Likewise, treatment programs report feeling more accepting of the data collection required, knowing that there is a purpose to each requirement. Finally, they are more likely to view data collection as part of good clinical management— not just paperwork. Put simply, there is no longer a feeling of administering forms simply to collect data. Directors of several other states have expressed interested in replicating this work in their state systems, and although these states are much larger than the pilot state, it is incumbent upon us to find a way to assist states, agencies, providers, and programs of every size to easily collect the information they need; to have the ability to use that information for decision making at the program, agency, and state level; and not to be sidetracked by collection of extraneous data that serves neither the state policy makers, the program directors, nor the patient. Acknowledgments Work on this project was supported by National Institute of Drug Abuse Grants R21 DA 19787, RO1 DA13134, and R01 DA015125. The authors would like to thank Amy D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109 Camilleri for her help in preparation of this manuscript. We would also like to thank the staff of the outpatient substance abuse treatment programs in the state of Delaware and Kim Beniquez at the DSAMH. Early results of this work have been presented at several conferences/meetings including the National Institute on Drug Abuse Division of Epidemiology Services Prevention Research Branch State Grantee Meeting in January 2008, the College on Problems of Drug Dependence June 2007 and June 2008, and the California State Agency/University of California Los Angeles Summit: Using Performance and Outcomes Measures to Improve Treatment in March 2008. References ASAM. (2006). 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