Private practice therapists need to keep track of quite a lot of information. During a typical workday, for example, you probably work with client diagnoses and health information, treatment notes and plans, appointment times, billing details, insurance, and more.
Many mental health professionals turn to practice management software to help increase practice efficiency. Reducing office management tasks allows more time for the actual business of therapy, and devoting the bulk of your work time to the job you actually want to do can increase your satisfaction with your work. It’s also likely to improve the therapy experience for your clients.
Digitizing client records in your private practice with electronic medical and health record software can have a positive impact on the care you provide to clients. It can also help you comply with HIPAA by making it easier to keep client records private and secure. Keep reading to learn more about these two types of software, including how to tell them apart and what yours should include.
What Is EMR Software?
An electronic medical record (EMR) is a key component of health care software. In fact, some practice management software platforms operate as electronic health records (EHRs) or have EMR functionality. Since EMR software often comes as part of practice management software, you could be using it already, if you use these digital tools in your therapy business.
Many organizations use EMR and EHR interchangeably, but they don’t mean quite the same thing. It’s important to understand the differences between the two since they could have a slightly different impact on client care in your private practice.
EMRs are simply digital charts. This record contains the health information you gather from a client at the start of treatment and the additional care information you generate during your work together.
An EHR, on the other hand, provides a far more comprehensive look at your client’s health. This record includes health history and information from multiple practices and care providers to create a detailed overview of physical and mental health history. Health care providers can safely and privately share this information between organizations, so all practitioners who care for your client can access important information about things like lab results, diagnosed health concerns, allergies, and medications.
As a mental health professional, you may be less likely to need to work with a client’s physical health information, although this information could still have benefit for treatment. EHRs can also help if your client has seen other behavioral health professionals.
What Should My EMR Software Do?
You may choose to collect and track client data using an EHR, based on the needs of your practice, but many private practice therapists find EMR software adequate.
When faced with a potentially overwhelming number of options, how do you choose the best EMR software for your private practice? You might begin trying to narrow down the field by considering the factors important to you, such as cost or ease of use.
Also keep in mind that ideally, good EMR software will lead to reduced costs and easier practice management, both of which can help improve the care you provide to your clients. Here’s how it works:
Track client health history
An EMR allows you to input and maintain client data over time. You can enter a client’s physical and mental health information at the start of therapy, then update it during the course of your work together—similar to how you might maintain a paper chart. The advantage to an EMR, of course, is its digital nature. You can easily view all information by looking at your client’s digital file, rather than have to flip through filing cabinets, multiple file folders, and so on.
Record previous diagnoses
An important part of your client’s overall health history is any past diagnoses, whether these are still relevant or not. An EMR offers an advantage here because it allows you to provide more extensive notes and details about past diagnoses and why they may no longer apply. Entering this information digitally not only gives you the opportunity to be more thorough, it helps prevent later confusion from illegible or cramped handwritten notes.
Track progress and/or psychotherapy notes
With your EMR software, you can take progress notes in a digital format. It may take some time to get accustomed to digital notes if you’re used to writing by hand, but you may find electronic notes helpful when trying to search for a specific date or session. Digital notes are also much more difficult to lose. Additionally, they’re more secure, if your EMR software is HIPAA-compliant (which it should be).
You may also be able to take private notes (process or psychotherapy notes) within EMR software, but these must be identified as such and kept separate from the progress notes, which you’ll need to share with insurance companies and other care providers on request.
Outline a treatment plan
With EMR software, you can quickly outline an approach to treatment and update it after each session. This helps you easily keep track of what’s working for a client, along with anything that isn’t working. You can also keep track of any therapy homework you assign and how your client responds and make notes on directions to take in future sessions.
An EMR can have incredible benefit when prescribing medication or a therapy approach. If you prescribe a certain drug, for example, the EMR can reliably notify you of any potential interactions with other medications, health issues, or allergies. This software can also alert you if a recommended therapy approach (such as exposure therapy or EMDR) hasn’t worked well for your client in the past.
Be HIPAA-compliant and secure
Your EMR software must comply with HIPAA (the Health Insurance Portability and Accountability Act), but this is something you can determine when choosing your software. If you’re using secure (HIPAA-compliant) software, you won’t have to take extra steps to secure client information as you might when dealing with paper files or files created in other types of software.
Easy access to ICD-10 codes
As a mental health care provider, you may have more everyday familiarity with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) than the International Classification of Diseases (ICD-10). The DSM provides information about mental health issues, while the ICD is a vastly more expansive diagnostic tool that covers both physical and mental health concerns.
If you do your own billing, you probably use the ICD-10, but you most likely also use the DSM-5 in your practice with some regularity.
So, you may want EMR software that allows you to not only search and access appropriate ICD-10 codes, but also allows you to cross-reference these codes with DSM-5 codes. Some EMR software does just that, so be sure to check for this functionality when making your selection.
Your specific software needs can depend on any number of things, including practice size, client requirements, and personal preference. When choosing any behavioral health software, it’s wise to spend some time doing research first to make sure you choose the software that best fits your needs.
You’ll also want to be certain any EMR software you consider offers functionality suitable for your therapy practice, since some software is designed specifically for medical practices and may not meet the needs of a behavioral health practice.
The American Psychiatric Association does not endorse any specific type of behavioral health software, but they do encourage professionals to research different types of EHR software and their functions to make the best decision for their practice.
- EHR: Frequently asked questions. (n.d.). American Psychiatric Association. Retrieved from https://www.psychiatry.org/psychiatrists/practice/practice-management/health-information-technology/ehr-faq
- Garret, P., & Seidman, J. (2011, January 4). EMR vs. EHR: What is the difference? Health IT Buzz. Retrieved from https://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference
- Holman, T. (2016, February 2). EMR compliance with ICD-10: What it means for your practice. Dignity Health. Retrieved from https://www.dignityhealth.org/articles/emr-compliance-with-icd-10-what-it-means-for-your-practice
- Mental health software. (n.d.). https://www.capterra.com/mental-health-software
- Understanding EMRs and EMR systems. (n.d.). Quatris Healthco. Retrieved from https://www.quatrishealthco.com/what-is-an-emr
- Uzialko, A. C. (2019, September 26). The best electronic medical record (EMR) software for 2020. Retrieved from https://www.business.com/categories/best-electronic-medical-records-software
- What are the advantages of electronic health records? (2019, May 16). Retrieved from https://www.healthit.gov/faq/what-are-advantages-electronic-health-records
- What is EMR? (n.d.). University of South Florida Health. Retrieved from https://www.usfhealthonline.com/resources/key-concepts/what-are-electronic-medical-records-emr