Electronic medical record (EMR) software—sometimes called electronic health records (EHR)—is rapidly becoming standard in behavioral health practices.
Some clinicians feel more comfortable using paper records and treatment notes or logging only minimal patient information in EMRs. Adapting to changing practice norms can be challenging, especially if you prefer to minimize your time spent sitting in front of a computer. But electronic medical records can revolutionize the way you deliver therapy, improving client outcomes while saving you time. Intelligent use of EMR can even help prevent mistakes and protect client confidentiality.
What Is EMR Software, and How Does It Work?
Electronic medical records are simply medical records maintained in an electronic format. Most programs require users to log in and view their records on a cloud-based platform. This is because accessing records via email is typically less secure, and your clients may not want to install a program on their computer or an app on their phone. Some programs allow clients to view a treatment summary immediately after each appointment. This can help them better understand their own health care while encouraging clients to focus on specific treatment goals.
There are dozens of different EMR programs. Many also offer practice management features, serving up an all-in-one approach to supporting your clients. When choosing a specific program, it’s important to read reviews, check to ensure the software has the features you need, and assess for usability.
How EMRs Improve Mental Health Care
Research shows that using EMR software can improve treatment outcomes. A 2017 study demonstrated that implementing EMRs reduced the rate of medication errors in behavioral health. Some other benefits of EMRs include:
- A more integrative care approach. You can track outcomes over time and assess which treatment strategies work best.
- Better patient profiles. Many therapists struggle with finding a system that enables them to remember key patient details during treatment sessions. With EMRs, you can code for the most important information and keep your notes in a single location.
- Tracking treatment goals. It can be difficult to assess whether treatment is working, especially when clients face new challenges or their treatment needs change. EMRs allow you to track client data over time, so you can measure which treatment strategies have proven most effective.
- Better record-keeping. Paper notes and records can be stolen. They’re easy to access, and easy to lose. With EMRs, you can maintain client records forever if you want. Well-designed software ensures that even diligent, persistent thieves cannot access client records. If a client asks for their treatment records, you no longer have to dig through a disorganized file. You may even be able to send the records electronically.
- Improved relationships with clients. When you can keep all client data in a single location, you’re less likely to forget important client information. That fosters stronger relationships and better communication, even when there are significant time gaps between sessions.
- Easier insurance payments. EMRs make it easier to document the specific treatment you’ve provided during each treatment session. That can help you bill insurance and support your billing practices if you are ever audited.
Connecting Mental and Physical Health
Mental and physical health are inextricably linked, yet our health care system often separates them. The medications your clients take may affect their mental health. Physical health conditions such as hypothyroidism and chronic pain may mimic symptoms of mental health conditions. In some cases, they may even be a trigger for mental health diagnoses.
Despite this, many mental health clinicians know little about their clients’ physical health. EMRs can change this. You may be able to integrate mental and physical health records, especially if you work in a large health system. Even if you don’t, EMRs provide an easy way to gather medical records and track changes in client mental health. Some programs even flag for known drug interactions.
With EMRs, you can seamlessly communicate with other clinicians, including psychiatrists, primary care providers, and any additional therapists the client sees. This helps you coordinate treatment strategy, minimizing the risk of bad outcomes and helping the client get the comprehensive treatment they deserve.
Strategies for Effective Use of EMR Software
As with any practice management tool, EMR only improves outcomes if you know how to use it correctly. To make the most of your EMR software, try the following:
- Ensure the program you choose is HIPAA-compliant.
- Use the program only in a HIPAA-compliant way. Never access patient information from a public network and avoid leaving your computer open with sensitive client data on it.
- Don’t just buy the program and forget about it. Encourage clients to register in your patient portal and regularly update their information.
- Look into options for integrating the medical records of other health care providers. Sometimes the easiest way to do this is to ask the client to enter their medical history. In other cases, such as if you are part of a large health care system, you may be able to share treatment notes and other relevant information with the client’s other providers.
- Get the client’s permission before sharing anything with third parties, including other health care providers. Some clients do not want their mental health history shared with other clinicians, even if they readily agree to share physical health information between providers.
- Spend some time familiarizing yourself with the program. Change can be hard, and if the program is not immediately intuitive to use, you might throw up your hands in frustration. Stick with it. If the software provider offers online training, invest the time to master the program. This enables you to serve your clients better and will probably save you time in the long run.
GoodTherapy supports therapists in practicing effective, ethical therapy and in streamlining their practices. We offer dozens of continuing education seminars, including guidance on using and implementing electronic medical record (EMR) software. Become a member and get listed in our high-traffic directory here.
- Manca, D. P. (2015). Do electronic medical records improve quality of care? Canadian Family Physician, 61(10), 846-847. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607324
- Monica, K. (2017, October 24). The importance of efficient EHR use in behavioral healthcare. Retrieved from https://ehrintelligence.com/news/the-importance-of-efficient-ehr-use-in-behavioral-healthcare