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EHR Ebook

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Whether you are a therapist, a psychologist, a social worker, or anyone else working in the field of behavioral health, you are likely to be familiar with Electronic Health Records (EHRs). Also referred to as Electronic Medical Records (EMRs), the early history of this technology dates back to the 1960s and 70s, when earlier versions of this tech were developed. This established the framework for the software that providers know and love today.

In the early years, EHRs were used but lacked the features and resources they now have. It would take further technological advancement to achieve their full potential. Their purpose was the collection of data for medical research purposes. Today, EHRs are defined by the Centers for Medicare & Medicaid Services as “an electronic version of a patient’s medical history that is maintained by the provider over time, and may include all of the key administrative, clinical data relevant to that person’s care under a particular provider.”

Under CMS’s definition, Electronic Health Records include clinical data such as:

  • Demographics
  • Progress Notes
  • Problems
  • Medications
  • Vital Signs
  • Past Medical History Immunizations
  • Laboratory Data
  • Radiology Reports.

EHRs have developed into a critical component of the care process across all specialties, including the behavioral health industry.

The Difference a Quality EHR Makes for Behavioral Health Providers:

Electronic Health Records play a vital role in operations, workflow, client/patient care, billing, and so much more for solo providers, large organizations, and everyone in between. The impact that a quality behavioral health EHR can have includes:

Increased Transparency 

Up until recently, it has been historically difficult for a patient/client to access their protected health information. Usually, only one version of their chart was kept in a file cabinet at their provider’s office, which was difficult to access. As time has progressed, there has been an increase in the value placed on data transparency between individuals and their providers. Why is this?

Client/Patient Engagement 

With more direct access to their own information, individuals start to play a more active role in their care, and a domino effect occurs as a result. In behavioral health, by providing your clients access to their chart, you give them agency regarding their care. They gain a better understanding of what progress they have made with their provider, the ability to review treatment plans so they can stay on track, and have a solid starting point for bringing up questions and concerns. Research has pointed to the positive impact of client engagement on adherence to treatment plans, attendance, and much more. EHRs now play a paramount role in improving the involvement of clients.

Quick Access 

Fast access to client/patient information enables behavioral health providers to offer more coordinated and efficient care to those they work with. Rather than shuffle through a paper chart to review the relevant information, recall previous encounters, or plan for the patient's future care, providers can locate the data they need in seconds. Digital charts enable behavioral health providers to quickly view what they need to effectively help those seeking services at their organization.

Information Exchange 

Electronic Health Records make it simple if individuals need their records shared with another mental health, behavioral health, or healthcare provider. Electronic Data Interchange (EDI)/Interoperability tools make it possible to exchange digital documents between organizations rather than rely on low-security fax machines or the patient to hand something to them directly. In behavioral health, providers often have to refer their clients outwards to other organizations to provide them with the care they need. In order to help the individual continue to get the care they deserve, their provider needs to have access to all of their previous history. EHRs make this not only possible but also makes it simple.

Higher Security 

Quality EHR software has been developed to offer the highest level of security possible when it comes to protected information. Whether you are exchanging protected health information (PHI) with another organization or you need to protect yourself from data breaches, EHRs are required to offer high-level security. The Health Insurance Portability and Accountability Act of 1996 has been amended to include regulations for Electronic Health Records to protect clients and patients.

Increased Accuracy 

Paper charts are notorious for being inaccurate sources of information. Unreadable handwriting leads to poor transcription or misunderstandings that have a long-term negative impact on client/patient care. Electronic health records enable next-level accuracy regarding the data in an individual's file by eliminating error-ridden processes. Instead, data is typed directly into their chart. This allows providers to reference a detailed history of past encounters, view accurate demographic information, and make well-informed decisions when working with individuals.

Improved Service Coordination 

EHRs, along with other Health Information Technology (HIT), are capable of improving service coordination for clients working with multiple providers. Interoperability and better information sharing enable a client’s network of providers to communicate and plan together more effectively. This has a lasting impact on the quality of that individual's mental and physical health care.

Quick Communication/Crisis Response 

Quickly communicating with a behavioral health provider (and vice versa) is an incredible resource during a mental/behavioral health crisis. Whether on mobile devices or via computer login, individuals can reach out to their providers should they experience a mental health crisis. Providers can quickly respond and put any necessary actions in motion so that they can get the help they need. This efficient communication can save lives.

Improved Overall Care 

Electronic Health Records have endless capabilities that enable behavioral health workers to stay on top of the details, making the best decisions they can for the people they care for. With coordinated, effective workflows in place, providers can increase the quality of the care they can deliver and improve outcomes over time.

Increase Client Satisfaction 

Whether or not your client is satisfied plays a considerable role in whether or not they continue to come to you for care, recommend your organization to others, and stay engaged in their care process. EHRs are proven to increase client satisfaction through increased access to information, communication, and resources that set them up for success.

So Much More 

The benefits of a quality behavioral health Electronic Health Records are endless. The real challenge is finding one that has everything you need to experience those benefits effectively. Not every EHR is the same. Some are only stocked with the bare minimum of tools to be certified under the CMS/ONC EHR certification standards. With EHRs having such a long history, there are vendors of this software that have nailed down helpful tools specifically designed with mental/behavioral health providers in mind. These tools have been curated for this specialty, for all different sizes and types of organizations, to create a seamless experience and improve a wide variety of client care, administrative, and billing processes.

12 Must-Have Behavioral Health EHR Tools/Resources:

Digital Intake

When it comes to getting clients/patients involved in their care, providers have more tools than ever at their fingertips. In the digital age, transitioning as many processes as you can into quality digital alternatives is the best way to engage those you work with. Digital intake changes how behavioral health providers collect the patient health information that enables them to offer the best care. Traditional intake, or the process of gathering client/patient information and history, was completed with paper and pen. Individuals coming in for a visit would first have to sit down and manually fill out intake forms so that their providers could have the information they needed to formulate a good starting point for their care.

Traditional paper intake is an error-ridden process that introduces quite a few issues into the care process. Those issues include:

Poor Handwriting/Manual Transcription 

Most individuals do not fill out intake forms with pristine handwriting. Why is this an issue? Well, when it comes time for a staff member to transcribe documents or incorporate them into an individual’s chart, important details get lost in translation. If handwriting is not readable, it does not help establish an accurate patient history, and errors are introduced into the care process.

Lack of Access to Relevant Data 

The more accurate information a behavioral health provider has at their fingertips, the better care they can offer. A detailed history enables therapists to assess knowledge across the entirety of an individual’s care, such as previous symptoms, previous forms of treatment, and more that helps formulate a plan for the future. Paper documents take time to transcribe and appear in the individual's chart. Even if a provider has access to the paper document, they cannot always assess them as quickly as they could a digital copy. Without access to the whole history, providers do not have the entire picture and are unable to make the best-informed decision.

Inefficiencies 

Paper intake is historically inefficient. It takes longer for the individual to fill it out and your staff (or yourself) has to transcribe it into the electronic chart. Even then, there is no guarantee it has everything you need.

While paper intake was once the best data collection method, better options are now available. Digital intake solves these issues by automating the intake process from start to finish. Patients fill out their forms online, from a client portal, before visiting. Providers can set requirements for what information the individual must input before the documents are considered complete. Once the individual has completed the forms, that data is uploaded directly to their chart, eliminating the transcription process and ensuring providers have all of the information they need before the visit.

A behavioral health EHR worth using should come equipped with digital intake capabilities so that you can introduce this process into your workflow as seamlessly as possible. Not only this, but individuals are more likely to complete digital forms than paper intake forms, engaging them in the care process from the start.

Integrated Therapy Notes

Notetaking is an essential and valuable component of any behavioral health provider’s job. Comprehensive notes that reflect a complete picture of the client’s time with you overflow into every other process. From forming treatment plans to tracking their progress, note taking helps providers offer better care.

Therapy notes are valuable because:

  • They Are More Reliable - Rather than depend on memory alone, therapy notes provide a dependable source of data for providers to recall information, track client progress, and make connections through the duration of the individual's care.
  • They Are a Detailed Record - Should this information need to be reviewed by another party (like a future provider), progress notes provide a detailed record of the client’s time with you, what has been accomplished, what interventions/modalities have been implemented, what has worked for that individual and so much more. Having a reliable, detailed account of the patient’s history and progress sets them up for success in the future.
  • They Help Formulate Treatment Plans - With a detailed record of the client’s progress in hand, behavioral health providers are able to make well-rounded decisions and formulate data-backed treatment plans. They can collect the individual's symptoms, behaviors, thoughts, and more to diagnose and treat clients to the best of their ability.

With so much value being placed on progress notes in therapy, providers need a highly effective method of completing their notes and collecting this data. There are behavioral health EHRs integrated with Wiley Practice Planner, which are designed specifically with this in mind. Integrated therapy notes, including SOAP notes and BIRP note templates, are easy to complete directly within the individual’s electronic chart. That information then remains easily accessible, meticulously organized, and conveniently located all in one place should you need them in the future. Providers can also find the most up-to-date set of diagnostic codes, treatment plans, discharge summaries, and more.

Not only this, but an integrated system allows clients/patients to review progress notes so that they can play a more active role in their behavioral health care. Just like progress notes help you remember your encounters, they help clients stay on top of the details as well. With this access, they can remember what they need to do to stay on track with their treatment plan, ask questions that they didn’t think to ask during a visit, and recall the information that was discussed during your time with them.

Integrated therapy notes in a behavioral health EHR improve clients' care process while also having a positive impact on provider workflow.

Streamlined Scheduling Tool

Behavioral health providers know just how challenging it can be to increase appointment adherence and reduce no-show visits. No-shows are costly and a waste of your professional time, so it is essential that they occur as little as possible, if at all. Your Electronic Health Record plays a considerable role in how well your clients adhere to appointments and how you as a provider stay organized. Research points to the benefits that systems like these can have on patient outcomes. Today, the best EHRs designed for mental health come equipped with top-of-the-line scheduling tools. What does this mean?

This means that providers have access to quality organizational scheduling software at their fingertips, integrated directly into their EHR. Quality scheduling software includes features such as:

  • Unified Calendar: Providers can create individual, group, telehealth, and multi-staff appointments all in one spot.
  • Filters - Calendars can be filtered by service type, staff member, location, and more for easy navigation and viewing.
  • Room Assignments - Do you offer services out of multiple rooms? Scheduling software makes it easy to assign appointments to specific locations, preventing any possibility of double booking.
  • Anonymity - Keep your clients anonymous by only using their initials in your calendar while still allowing other members of your organization to view your schedule. You can also sync your work calendar with your other calendars without putting the client at any risk.
  • Client Portal Integration - Keep your client aware of their appointments and forms while giving them access to secure messaging should they need to reschedule or as a question using an EHR integrated client portal.

Scheduling software should also come with features that help you cut down time spent on administrative tasks such as:

  • Updates - Update notifications regarding your calendar are sent directly to your email so that you are always prepared for your day. If your schedule has changed or you’ve had a cancellation, then you can adjust accordingly.
  • Automated Reminders - It is no longer necessary to chase down patients to make sure they remember their appointments. Automatic reminders can be sent via voice call, email, or text message.
  • Track Attendance - Do you need to keep track of how often individual or group therapy sessions are being attended? A behavioral health scheduling tool in your EHR can do it for you.

At the end of the day, scheduling software is meant to help behavioral health providers streamline their administrative processes, stay organized, and better help their clients. Your EHR should be capable of supporting those functions alongside every other important feature.

Appointment Reminder

As we just mentioned, appointment reminders are an essential feature to have in your EHR scheduling tool. In the field of behavioral health, appointment adherence is vital for everyone involved. It is crucial to provider success because there is no work if individuals do not show up for you to offer services. More importantly, patients benefit from coming to their appointments. Adhering to all scheduled appointments helps individuals stay on top of their treatment plan, get the help they need from their provider, and play a more active role in their care (which we’ve established as being very important to their success).

When an individual misses their appointments, it is rarely on purpose. Things come up, lives become busy, and individuals forget to put the visit on their calendar. The most effective way to prevent no-shows is to give clients resources to help them remember their appointments. The best EHRs should come with the ability to sign your clients up for automated appointment reminders. Automated reminders are a proven method for getting clients to better adhere to their schedule by helping them remember when and where they need to be.

Let your client choose what works best for them. Do they rarely check their email but always look at their phone? Sign them up for text reminders instead of email. Are they likely to pick up a phone call? Schedule them for voice-call reminders. Do they need an arsenal of reminders to help them stay on top of every detail? Sign them up for all three types.

A quality EHR is designed with functions that set providers and their clients up for success from the start. The right one can

Administrative Functions

Administrative functions are a necessary component of every organization that often consumes far more time than they should. This time should be spent with clients instead of managing documentation, charts, notes, signatures, and so much more. When these processes are completed manually, that work compounds in size. Instead of just collecting a signature, staff has to collect a signature, scan that signature into the system, and file it away. If documents need to be accessed in the future, they take too much time to locate.

Behavioral health EHRs are designed for more than just helping you through the service side of your job. They can help with every administrative responsibility you face. A quality software solution should be able to help you with things like:

  • HR Document Management
  • Electronic Client Chart Management
  • Supervisory Review and Co-Signing Options for Therapy Notes
  • Digital Signature Collection for Both Client and Staff
  • And More

By digitizing these processes, providers are able to work more efficiently. According to the Office of the National Coordinator for Health Information Technology (ONC), studies have shown that EHRs have an impact on organizational efficiency. They report that providers spend less time with chart management, can access information more easily, scheduling is improved, there is a reduction in manual paper processes, and there is better information sharing.

With all of this in mind, EHRs can significantly improve a behavioral health organization's productivity and workflow efficiency. They effectively reduce administrative burden and allow more time to be allotted to clients who need it.

Reporting Features

Data is everything in this field. In-depth reporting and analytics help you gain insight into how your organization is doing, how your clients are doing, what areas of your workflow need improvement, and so much more. The value of this data is being able to stay on top of every moving detail, make changes when necessary, catch inefficiencies in their tracks, and better serve the individuals coming to you for care. Your behavioral health EHR should be equipped with reporting features across all processes such as:

  • Referral Tracking - Track and compare referral sources to learn which ones result in the most significant number of new clients.
  • Client Care Reports - Better understand which interventions are best helping your clients reach their goals.
  • Client Demographics Reports - View client distribution by specific demographics, including gender, race, marital status, and more, to help focus your marketing efforts on the demographic to which you have the most experience.
  • Attendance Reports - View the attendance for individual and group sessions.
  • Retention Rate - Assess how long individuals seek services with you or your organization. Learn if there is a common reason for their leaving or if there are steps you can take to keep clients coming back.
  • Revenue Reports - Examine your revenue breakdown to determine what types of clients result in the most remarkable financial growth for your practice.
  • Claim Process Reports - Identify common errors in your claims process, such as frequent mistakes in billing codes, to improve clean claims.
  • Payroll Reports - Make sure your administrative processes are working from start to finish. Quickly pull up payroll reports to ensure your staff is getting paid the way they should.

The list doesn’t end there. An Electronic Health Record for behavioral health providers should supply all of the resources necessary to help your organization function at its best through every process. Having access to data like this enables providers to make major decisions that benefit their organization and clients.

Electronic Billing

Behavioral health billing is one of the more challenging and burdensome processes that providers have to navigate. The nuances that are woven into every step cause headaches for organizations everywhere. While not every provider accepts insurance, those who do know the hurdles that come with behavioral health billing. Memorizing billing codes, filing claims, navigating payer regulations, and managing denials are pain points that a billing-integrated EHR can help relieve.

With your billing tools combined into your EHR, you can streamline your claims process to achieve more in-full and on-time payments. Features of a quality EHR billing tool include:

  • Clearinghouse - A clearinghouse is a middleman between payer and provider that makes sure your claims are primed for approval. With an integrated billing tool, providers can easily submit primary and secondary claims through a clearinghouse for cleaner claims and faster payments.
  • Automatic ERA/EOB - Quickly process Explanation of Benefits(EOB or ERA for electronic versions), integrating that data directly into the client’s portal for their viewing and understanding.
  • Reporting - Understand where billing errors are occurring the most, what payers you have the most trouble with, and how to improve your billing process from start to finish.
  • Claims Tracking - Track your claims from submission to payment to make sure they make it to the payer and quickly respond to denials should they happen.
  • Batch Submission - Easily submit multiple claims at once.
  • Forms & Templates - Create, print, and download CMS 1500 forms and access thousands of pre-written treatment goals, objectives, and progress notes while still having the space to create your own with Wiley Practice Planners.
  • Updated Billing Codes - Access the most up-to-date set of CPT codes and code modifiers, making sure you are always using the correct codes to file your claims.
  • Payer Requirements - Stay on top of complicated payer requirements to ensure you continuously comply with their standards.
  • Denial Management - Easily manage denials, making sure revenue does not slip through your fingertips.

With integrated billing, providers can increase their clean claims, make bills available to clients more easily, quickly catch denials, better understand their revenue cycle, and so much more. Having these tools within your EHR enables you to streamline your workflow from one process to the next, documenting on one page and filing a claim on the next. With everything in one spot, you get more done in less time

Client Portal

The more tools you can provide your clients, the more successful they are. Resources are everything in behavioral health. The more tools a client has on their belt, the better equipped they are to navigate various life situations. The same is true for the care they receive from you. With more resources, they are more likely to navigate and participate during their time with you successfully.

A quality EHR will come with an integrated client portal designed to be an engagement hub for your clients. Here, they can message you, view their bill, review their treatment plan, and more to play a more active role in their care. With a tool like this, individuals are better equipped to do things like remember their visits, ask questions, and pay their bills. A quality behavioral health EHR client portal will have the following features:

  • Digital Intake - Clients can fill out their intake forms at home, prior to their visit.
  • Client Records - Clients can easily view their record and treatment plan to recall important details and stay on track.
  • Communication Tool - Give clients an additional way to get in touch with you to ask follow-up questions regarding their plan. Send HIPAA compliant messages and share files securely so they can continue to feel connected.
  • Self-Scheduling - Free up your staff’s time by giving clients the ability to schedule, cancel, and reschedule appointments online. This helps reduce no-show visits by giving clients a convenient way to manage their appointments.
  • Anywhere Access - Give clients the ability to access their account from anywhere.
  • Payment Processing - Help clients review their bills so they can better understand them while giving them an easy way to pay them with online credit card processing.

Client portals help give individuals agency over their care, connecting the dots between visits while giving them essential reminders about their bills and appointments. Every EHR should come with a state-of-the-art client portal. Research points to the idea that EHR client portals are valuable in facilitating a better client-provider relationship.

ePrescribe

EPrescibe, or Electronic Prescribing, is growing in use as more states across the country implement ePrescribe mandates. The reasons are that electronic prescriptions offer increased client safety, reduced drug costs, in-depth records of prescriptions, and an overall more efficient workflow. With the country trending toward a nationwide mandate on this tool, it is important that providers find a behavioral health EHR that offers it. A quality ePrescribe tool will come with features such as:

  • Medication Management - Providers can write prescriptions, manage medications, and handle refills within their accounts.
  • Controlled Substances - Easily write prescriptions for controlled substances with multi-factor authentication.
  • Point-of-Care Tools - Let your EHR support clinical decision-making with drug-drug, drug-allergy, and dosing contradiction checks.
  • Medication History - Quickly review the client's medication history over the last 12 months at a glance.
  • Cost Transparency - Increase medication adherence by offering more transparency regarding prescription costs. Perform formulary checks to show your client’s actual out-of-pocket costs at the pharmacy.
  • Accuracy Measures - Reduce medication errors with accuracy measures in place.

The list doesn’t stop there. EHRs with integrated prescribing tools are an effective way to increase medication adherence and monitor meds closely.

Integrated Telehealth

Telehealth has revolutionized the field of behavioral health by eliminating barriers to care while simultaneously changing how we think about what it means to offer services. Telehealth is the process of providing behavioral health services to clients without being in person. Telehealth, also called telemedicine or teletherapy in this case, is primarily provided online via computer, tablet, or smartphone. Why is this so revolutionary to the field?

  • Eliminates Barriers - Historically, mental and behavioral health services have been notoriously difficult to access. In the past, individuals who lacked transportation, lived outside of a provider's geographical region, or could not get away from work were simply unable to receive the services they needed. With telehealth, individuals can access their mental health provider from their phone or computer, making them more accessible.
  • Reduces Shortage of Services - With online therapy, providers can broaden their geographical range for what patients they can see. They can also see more clients in less time. An integrated telehealth/EHR solution makes jumping from visit to visit painless, simplifying each workflow along the way. With a streamlined workflow and broader reach, providers can work with more clients.

The pandemic caused telehealth usage to grow as more individuals opted to receive care from the safety and comfort of their own homes. Expanded coverage that was established during the pandemic is now becoming permanent, and individuals are expected to continue using it as a resource for their care. Make sure your behavioral health EHR is equipped with a top-of-the-line telehealth solution that offers usability, seamless integration, and a quality client experience.

Easy-to-Use Interface

Usability is highly important in any form of HIT. The software you choose might have all of the right features, but if it is difficult to navigate, use, and understand, then it is useless to you. Usability impacts efficiency, the patient experience, provider burnout, and productivity.

If the software is difficult to use, then your workflow is stunted. Tasks that you should be able to breeze through suddenly become time-consuming and challenging. This later translates into burnout and frustration.

The behavioral health EHR that you choose to implement at your organization needs to have a strong, easy-to-use interface that supports you rather than hinders you. It should be simple to navigate, easy to understand, and support the natural flow of your workday. It should ultimately guide you to relevant information and the tools that help you work more efficiently and accurately.

First Rate Support

Alongside the usable software, a quality support team should be ready to help you implement it and answer your questions along the way. Features of a quality behavioral health EHR support team include:

  • A team that is available when you need them.
  • Support that is easily accessible through multiple channels, including phone support.
  • A support center that has help articles and videos covering the totality of your software along with 24/7 on-demand training classes that cover each and every feature of the software.
  • The ability to message with your vendor within your account to ask questions or share feedback.
  • A hands-on team that will guide you through the implementation process.
  • The ability to easily migrate/import your current client demographic and insurance information with a few clicks.

Your EHR vendor should always be there to help you through the growing pains of adopting new technology while establishing the infrastructure for future success.

A specialty-specific behavioral health EHR should be equipped with every tool and resource to help you breeze through administrative work, perfect your revenue cycle, and better help your clients. Find an EHR with each one of these tools/integrations along with quality customer support, and you will have a valuable resource to help your organization succeed.

To learn more about an EHR designed for mental and behavioral health providers and to schedule a free trial, click here.

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