Not sure what to consider when looking for an EHR for substance use? Trying to determine if a mental / behavioral health EHR is right for your substance use agency?
An EHR, or electronic health records (also referred to as an EMR or electronic medical records), is an electronic form of paper charts. There are tons of EHRs for general and specific medicine, but an EHR for substance use requires functionality to address the complex needs of addiction treatment.
Whether you are an Intensive In-Home (IIH), Day Treatment (DTx), Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP), most often you’ll find that mental and behavioral health EHRs have all the built-in functionality necessary to operate your organization smoothly.
A mental health EHR can be instrumental when it comes to substance use case management, addiction treatment planning, crisis management, and coordinating care among multiple providers – which can prove to be a hefty challenge!
In order to meet the demands of substance use treatment centers and addiction rehabilitation facilities, an EHR’s functionality must account for both the operational needs of the agency and unique functional needs for clients – be it for day treatment or inpatient-specific options. Ideally, your EHR can also support integrated case management.
In shared clinical decision-making, record management; treatment plans; medication management; and follow-up protocols need to be clearly communicated. Comprehensive note management capabilities in an EHR, for example, can keep assessment, progress, group, and team notes in one cohesive place. This capability helps to monitor a client’s progress and ensures that information, authorizations, and any sort of incident reporting or discharge planning attached to a client’s chart is easily accessible.
Other EHR features that can help substance use organizations more efficiently & effectively treat patients and coordinate care include:
With lab integration, an EHR automatically uploads lab results directly into a client’s chart in your software. From there, you can flag any criteria you are monitoring and also access global reports based off results, which can help clinicians analyze them within a broader context. This integration also keeps any multiple parties involved in treatment planning and medication management on the same page.
E-Prescribing allows doctors, physicians, psychiatrists, and medical practitioners to electronically send prescriptions to a pharmacy. When integrated with an EHR, you can also manage medications, ensure there are no drug-to-drug or drug-to-allergy interactions, and view client history. Treatment teams can also see what has been prescribed in the past, as well as any current prescriptions.
If you are an inpatient facility, bed management is key! This feature allows you to see the status all of the patients in your organization in real time. Bed management can empower you to schedule beds, manage a daily attendance log, keep notes on clients, and get alerted when a bed becomes available. It can also provide the treatment team easy, efficient access to charts and notes.
Electronic Medication Administration capabilities allow you to track who administered medications to a client, as well as what meds; where they were given; and when. This feature provides top notch medication accountability and also reduces administrative errors. Additionally, built-in inventory allows a facility to track the medication bottles and will auto-decrement the bottle counts according to what has been dosed. This tracking is associated with the original package – and even individual pills!
eMAR functionality will certainly prove to be useful for inpatient care, day treatment, intensive outpatient, intensive in-home treatment programs, and dosing clinics.
HIPAA compliance, adherence to 42 CFR Part 2, and personal health information (PHI) security is especially crucial for substance use facilities and addiction treatment centers. In order to protect the confidentiality of this data and ensure compliance, an EHR needs to have secure hosting that adheres to both HIPAA and 42 CFR Part 2 protocols. This means encrypted communications and operation processes, the blocking of unauthorized traffic, and rigorous threat management.
Aside from the above-mentioned functionality, whether you are an Intensive In-Home (IIH), Day Treatment (DTx), Intensive Outpatient Program (IOP), or Partial Hospitalization Program (PHP), you might benefit from robust electronic billing functionality, accountability tools, and reporting features.
If your EHR can customize reports for you – WINNING! But at the least, an EHR will certainly help streamline data entry and save your agency time and money, while also helping you better meet the needs of your clients.