EHR for Substance Use

Are you unsure what to look for in an EHR designed for substance use, or trying to figure out if a mental/behavioral health EHR is the appropriate choice for your substance use agency?

What is an EHR for Substance Use?

An EHR, or electronic health record (also referred to as an EMR or electronic medical record), is an electronic form of paper charts. They are solutions to store your patient data and documentation digitally. Think of them as electronic filing cabinets!

There are tons of EHRs for general and specific medicine, but substance abuse EMR software 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 improve your practice management and run operations smoothly.

EHR for Substance Use, Care Coordination, and Addiction Treatment

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!

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 the unique needs of the 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 must be communicated clearly. Comprehensive note management capabilities in an EHR, for example, can keep assessment, group, team, and progress notes in one cohesive place. This capability helps monitor clinical outcomes and ensures that information, authorizations, and any sort of incident reporting or discharge planning attached to a client’s chart are easily accessible.

EHR Functionality for Substance Use Treatment

Here are EHR features that can help substance use organizations more efficiently & effectively treat patients and coordinate care:

// Lab Integration

With lab integration, an EHR automatically uploads lab results into a client’s chart in your software. From there, you can flag any criteria you want to monitor (such as having all positive drug tests appear red in the results) and pull global reports based on these results. This helps clinicians gather patient records and analyze test results within a broader context.

This integration also keeps multiple parties involved in treatment planning on the same page. With lab integration, you can attach the results to the client chart without scanning, typing, or entering any data. Allow your clinicians easy access to all the patient information they need!

// e-Prescribing

E-prescribing allows doctors, physicians, psychiatrists, and medical practitioners to send prescriptions electronically to a pharmacy, eliminating the need to fax or call them in. Connecting the point of care directly to the pharmacy improves communication, medication management, and overall business operations.

When integrated with an EHR system, you can easily view the client’s medical history, meaning treatment teams can see what has been prescribed in the past and any current prescriptions. This decreases the risk of medical error or prescription fraud, minimizes the risk of drug-to-drug or drug-to-allergy interaction, improves medication adherence, and increases patient safety.

If you are a psychiatrist or a clinician responsible for prescribing medication, your organization may benefit significantly from e-prescribing integrated with your EHR.

// eMAR

Electronic Medication Administration capabilities allow you to track who administered medications to a client, what meds, where they were given, and when. This feature provides 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 be useful for inpatient care, day treatment, intensive outpatient, intensive in-home treatment programs, and dosing clinics.

// Bed Management

If you are an inpatient facility, bed management is key! This feature allows you to see the status of all the patients in your organization in real time. Bed management can help you 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 with easy, efficient access to charts and notes.

For agencies offering inpatient treatment, you need to be able to see the real-time status of all the clients in your facility – and create a daily bed attendance log and daily notes for everyone in the program. With PIMSY’s color-coded bed management screen, you can quickly and easily schedule beds, maintain a waiting list, and determine when a space should become available. Organize your patient population with efficient bed management tools.

// UB-04 Billing

UB-04 billing is a type of medical billing an institutional provider can use for the reimbursement of mental health insurance claims. Billing for IOP and inpatient services is a unique functionality that some substance abuse treatment software does not consider when creating billing rules and procedures. Your EHR system should include billing software tools that give you full control over the type of bill, attending provider, and rev code specifics for all inpatient claims, including residential facilities, IOP/PHP services, and other institutional claims.

// Comprehensive Session Notes

Strong note management capabilities in an EHR help monitor a patient’s progress, avoid redundant treatment, and encourage adherence to the treatment plan. Robust notes – of various types – also ensure that all information in a client’s chart is integrated and easily accessible.

EHRs offer customizable, comprehensive templates for the specific needs of your practice. They include all four note types: assessment, progress, group, and team. You can tailor the notes to your specifications and pull treatment plan goals directly into the note.

// Telehealth Integration

Telehealth is a comprehensive healthcare approach that assists with long-distance patient care. It involves delivering mental health support through video chat, phone calls, or text-based communication, accommodating varying intensities from brief sessions to regular appointments. This integration increases patient engagement, allowing them to access care from anywhere!

PIMSY has partnered with Secure Video to offer integrated HIPAA-compliant telehealth services. This capability allows you to conduct a session right from your PIMSY calendar and send automatic meeting invitations and appointment reminders.

EHR for Substance Use Compliance Tools: Security, HIPAA, & CFR Part 2

// Secure Hosting

HIPAA compliance, adherence to 42 CFR Part 2, and personal health information (PHI) security are especially crucial for substance use facilities and addiction treatment centers. To protect the confidentiality of this data and ensure compliance, an EHR needs to have secure hosting that adheres to HIPAA and 42 CFR Part 2 protocols. This means encrypted communications and operation processes, blocking unauthorized traffic, and rigorous threat management.

// MIPS – Meaningful Use – MACRA

For many facilities that treat clients under Medicare and/or Medicaid, payment adjustment programs such as Meaningful Use, MACRA / MIPS, and PQRS are an essential part of daily operations. Be sure to check with your billing and compliance departments to determine if you require an EHR that is certified, to participate in applicable programs.

What else to consider in a Substance Use EHR?

If your EHR can customize reports for you – you are WINNING! Att the least, an EHR will undoubtedly help streamline data entry and save your agency time and money while also helping you better meet the needs of your clients.

Aside from all of 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 the robust features of an Electronic Health Records Software. These features streamline operations, improve the professional services of your mental health  practice, and reduce the administrative tasks of your providers.