EHR Implementation

Electronic health record (EHR) implementation might be exactly what you need if you’re currently using paper charts in your counseling practice or other practices like speech, occupational or physical therapy. Paper charts can present challenges with organization, management, maintenance, and storage. An EHR can help your practice run more efficiently while providing clients with greater satisfaction and better treatment outcomes.

What is an EHR?

An electronic health record (EHR) is a digital method of maintaining a client’s chart. An EHR is more than keeping electronic notes stored on a computer, however. It is an entire software system that securely stores, retrieves, and shares clinical and general information related to a client in one digital location.

An EHR allows for instant access to real-time information by authorized users. EHRs often manage:

• Clinical documentation (notes, assessments, discharge summaries)
• Treatment planning
• Demographic information (contact information, date of birth, emergency contact)
• Insurance information
• Space to upload documentation provided by other providers or parties
• Access, usage, and storage for assessment tools and homework
• Calendars (usually syncs with other calendars used by the clinician)
• Forms and intake paperwork (can be electronically signed by the client)
• Appointment reminders
• Insurance verification and electronic billing
• Secured messaging with the client

Most therapy practices use a cloud-based EHR system. In a cloud-based system, the EHR vendor hosts the server remotely and the therapist pays a monthly fee to the EHR vendor. Some practices may choose to purchase an EHR system and host it locally on a server in the office. This article will primarily address a cloud-based system.

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Why make the switch to an EHR?

Change is hard. As a therapist, you may help people work through changes every day. So why switch from a paper system to an EHR? EHR implementation offers many benefits to your practice but it takes time, effort, energy and planning to make the switch. So, to help find that motivation to implement the change, take some time to define your reasons for the change. What big goals do you have for an EHR implementation?

Some questions to consider for your switch:

• Why do I want to go paperless?
• How much money and time will it save me?
• Can I work more efficiently?
• Will EHR implementation help to streamline my practice?
• Will an EHR improve my treatment outcomes?
• Can EHR implementation simplify my documentation?

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Benefits of an EHR

Automation

EHRs help to automate your practice. With an EHR, the client’s information is entered once and populated across multiple locations within the chart. For example, when the client chart is created, demographic information such as the name, address, and date of birth will automatically populate in the clinical notes, billing forms, and the treatment plan. Once the clinician enters the diagnosis, the same diagnosis will appear on all the documentation.

Automation helps to:

• Organize the practice
• Decrease the amount of work to maintain a chart
• Reduce data entry errors
• Eliminate the need to flip back and forth across pages in a paper chart or multiple software programs
• Save time and energy spent on client charts.

Efficiency

With an EHR implementation, the practice can run more efficiently because one software program can manage the multiple, but necessary tasks required for a counseling, speech, physical or occupational therapy practice.

EHR implementation can address:

• Scheduling: Clients can directly schedule an appointment at any time. They do not need to schedule during business hours of the practice. While at the office, appointment scheduling does not require answering, initiating, or returning phone calls when clients can directly schedule their appointments.

• Payments: Clients can use the portal to make payments. Office staff or the clinician can process payments directly from the EHR.

• Paperwork: Clients can complete and sign the necessary forms and paperwork before a session.

• Automated appointment reminders: Automated appointment reminders take less time than other methods such as reminder phone calls. Appointment reminders help to decrease the no-show rate and increase client engagement.

• Insurance claims and eligibility verification: Some EHRs can verify insurance eligibility and submit claims to third-party payers.

Accessibility

Paper charts limit access to the physical location of the chart. With EHR implementation, approved users have access to client charts from any location at any time. With a simple login to the EHR, authorized users can access charts from home, from a second office location, or even while traveling. This accessibility removes the risk and liability of transporting charts to complete documentation after hours or when working at an alternative location.

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Security

Secure Records

EHR implementation offers more secure records management than a filing cabinet with paper charts. Paper charts, in a filing cabinet or sitting on a desk, are more vulnerable to theft than a secure EHR. For example, someone who wants access to a client chart can break into a locked office, a locked filing cabinet, or take a chart off a desk. Gaining access to a chart stored on an EHR requires much more knowledge and work to breach the data.

Paper charts can very easily be lost, damaged, or destroyed. A cup of coffee can spill on the chart; an office can flood; and, a briefcase transporting files can be lost. With an EHR, files remain safely and securely stored on a cloud-based server.

Secure Communication 

EHR implementation typically offers secure messaging services to communicate with clients and within the office. The messaging features offer a higher level of security than email. It is very easy for the wrong person to see an email. For example, an abusive partner, an employer, or a parent can easily see someone's email. With a secure message portal, the client must take the measures to log into a client portal to use the messaging feature. It presents another level of security above an email.

Documentation

• EHR implementation can reduce much of the stress, time, and liability that comes with documentation

• Documents are more secure and HIPAA-compliant when maintained in the secure EHR cloud than a paper chart

• Paperless intakes and ongoing upkeep with forms

• Important and necessary client information populates across documentation and forms (name, diagnosis, date and time of the session, treating provider name and signature, CPT codes)

• Reduces errors due to the streamlined processes

• No handwriting to decipher on forms and documentation

• More likely to contain correct insurance-mandated required elements

• May be easier to complete with templates and other features

• Treatment plans and session notes can flow seamlessly together

• Some EHRs offer integration with a Wiley Treatment Planner program

• Integration of session notes, treatment plans, assessments, and discharge summary.

Reduces costs

While EHR implementation is not free, the time and money invested in an EHR can reduce costs. When you eliminate paper charts, you will not need to print out endless amounts of forms and documents needed for a chart which saves money on paper, printer/copier ink and toner, file folders, and other office supplies. You will need fewer file cabinets. Fewer filing cabinets can also save you on office space resulting in renting a smaller space or using that space for other purposes.

EHR implementation also offers financial support that can help you to track and process payments. Many EHRs offer a variety of financial reports that alert you to missed payments, compare monthly claims and copayments, and predict future trends. Such services can help to better account for your earnings and follow up with missed or late payments.

Improved customer service

Stronger customer service can improve client satisfaction and engagement which can ultimately improve treatment outcomes. One way an EHR can help is through paperless intakes. Clients can complete their intake paperwork online in the comfort of their homes. They can take the time they need to enter the information and answer questions. They do not have to feel rushed or pressured by doing so in the waiting room. The paperless intake process also allows the therapist time to review it before the session begins to ensure accuracy and prepare any questions for the client.

Clients also can maintain a connection with the practice when the office is closed by submitting any homework or assessments through the portal, making payments online, and scheduling appointments.

Risks

EHR implementation does present some risks for the practice. A thorough risk management plan can help to address the risks and lower any potential threats.

Cybersecurity Issues

Unfortunately, data breaches present a threat and risk in today’s society. EHR implementation is vulnerable to being compromised by a data breach and a client’s personal information being stolen. Most EHRs should have security measures in place to protect from threats so make sure to learn about the protection each EHR offers when researching and selecting your EHR. Cyber liability insurance can help to financially reimburse or support you in case a data breach happens.

Technology Issues

Sometimes technology can fail. Power outages can happen. You may lose internet access. A computer may need repair. When technology fails, it can interfere with access to the EHR. It is important to have a plan and policy in place to address what to do when technology fails.

Some possible backup plans can include:

• Remote internet access hotspot

• Secondary computer to use in case of a broken or damaged computer

• Alternate location to use in case of a power outage or lost internet connection

Discomfort with Using Technology

For some people, technology and EHR implementation can be intimidating. Switching from a paper-based charting system to an electronic system can seem scary and overwhelming. Some people within the practice may not want to use the EHR because of technology fears.

Some things to help with this risk include:

• Utilize available training resources and supports provided by the EHR

• Watch how-to videos on the internet for the EHR

• Allow extra time at the beginning for documentation and data entry