How to choose the right mental health EHR for your practice

Behind every successful mental health practice is an electronic health record (EHR) program that keeps track of notes, billing, and more. But when it comes to mental health, not all EHR programs are equal. 

The information management needs of a mental health care professional are unique, and your EHR system can make or break your practice. Learn more about the qualities all mental health professionals need to look for in an EHR and how to find the right one.

EHR vs. EMR for mental health

Before choosing an electronic health record (EHR) for your practice, it helps to understand how it’s different from an electronic medical record (EMR). The two terms are frequently used interchangeably, but they are different. 

• Electronic Medical Records (EMRs) focus mostly on clinical documentation. These systems can help individual clinicians manage records efficiently, but when it comes to multi-clinician practices or sharing information outside the organization, they’re limited. 
• Electronic Health Records (EHRs) have more capabilities. They are designed for holistic care coordination and allow clinicians to share data outside the practice. 

In this article, we’re mainly focusing on EHRs. 

What is the EHR problem in mental health care?

An EHR for hospitals and an EHR for mental health differ in many ways. EHRs for physical healthcare generally don't meet all the needs of mental healthcare. Traditional EHRs developed for hospitals tend to focus on things like medication management, imaging, and lab results. However, mental health care depends on sensitive client communication, nuanced documentation, and session-based billing. 

Between a lack of integration, usability issues and being a generally poor fit for behavioral health workflows, many behavioral health clinicians struggle to find workarounds for a system that is not designed for them.

Inevitably, this leads to workflow disruption, potential compromises in providing excellent patient care and poses a significant burden on providers. Many providers struggle with the negative effects of poor software. This increases the risk of burnout and disorganized workflows that ultimately hurt patient satisfaction.

What makes a mental health EHR different?

Mental health professionals need a solution that makes documentation, billing and compliance easier. This includes using time-based CPT codes and tailoring treatment based on relevant DSM-5 diagnoses. Therapy sessions vary in goals, length, and other details, so a basic EHR system that works for a general doctor may not be suitable for mental health providers.

There is a growing need for both privacy and empathy in electronic health records. Mental healthcare data includes personal information like therapy notes and substance use history. Because this information is so sensitive, strict privacy guidelines are necessary to protect patients.

These records should cater to the emotional and cognitive needs of patients and have a user-friendly design that makes administrative tasks easy to manage.

Dedicated mental health EMRs can provide: 

• Better privacy controls
• Mental health templates and workflows 
• Intuitive design and privacy 

All of these make clinical documentation more human and smoother for behavioral health practices and clinicians. 

The limitations of legacy systems

If you're using a legacy electronic health record system, you've probably had some significant issues with it. For example, you may have used workflows that don't make sense, or have issues with storing patient data and security risks because of design flaws.

Some of the biggest problems are due to a lack of specialized workflows and documentation. Many of these models are designed for general medical information. They don't support the unique narrative or flexible documentation styles that are essential for making seamless connections between assessment, treatment planning and progress tracking. This is otherwise known as the "golden thread" standard of integrated documentation.

Many EHRs may claim to offer "robust" record-keeping options that are actually too complex and unnecessary for mental health records. Some systems come with hidden costs for features that you don't need (or want). Inefficient systems that don't cater to your specific needs can create confusion, especially when trying to verify and organize patient data from different sources.

The rise of AI-powered EHRs

Like many other industries, healthcare has changed because of AI, specifically in the realm of AI-powered behavioral health EHRs. Note-taking and treatment planning can be made easier through the automation of administrative tasks. This simplifies the way you work, including an easier way to gather information. Ultimately, this improves patient engagement and care coordination.

Automation also helps improve clinical decision support by reducing (and not replacing) clinical judgment. For example, AI EHR software algorithms can look at data, identify concerning patterns and flag high-risk individuals. Through this data, it can then suggest evidence-based interventions or adjustments to the treatment plan. With AI, you will improve your diagnostic accuracy and know when to start earlier and more proactive treatment.

How a modern EHR should work for therapists

As AI continues to improve, it is an important feature that EHR companies are integrating into their platforms. If you're looking for a new EHR system, there are several things you should consider as a therapist, including:

• How seamlessly it can be integrated into an existing workflow
• If it offers clear, explainable outputs with full clinician control
• Whether it's rooted in an ethical design that's fully grounded in clinical evidence
• Whether it provides robust support for documentation and clinical decision-making

Along with these features, a modern electronic health record should offer many features that allow you to seamlessly integrate and automate administrative tasks (like calendar building, billing, note-taking and telehealth).

An AI scribe feature is especially useful for mental health professionals since it can transcribe conversations in real-time. It can also help you turn summaries from therapy sessions into clinical notes. This feature can substantially reduce your time spent on paperwork.

A therapy EHR should also feature customizable smart documentation that connects notes, treatment plans and goals for therapy. One of the benefits of integrating AI with these templates is that they can learn your documentation style and auto-populate all relevant fields. A compliance checker helps ensure consistency and adherence (which protects against audits and clawbacks).

Another great feature to look for is billing and coding assistance. These administrative tasks take up a considerable amount of time. However, the right AI-enhanced EHR can analyze documentation, suggest appropriate billing codes and verify insurance in real-time. These features can reduce your number of claim denials and streamline your revenue cycle.

Introducing the Operating System Vision

At Upheal, we are creating AI-powered tools to provide better balance for mental health professionals. For this reason, our products are built by clinicians who understand what you need to run a successful, client-centered practice.

There is so much potential for AI to help empower the working lives of mental health care professionals, whether it's through automating administrative tasks, taking over large portions of practice management, or both.

Security, privacy, and trust are at the forefront of what we do. In addition, we offer AI tools that protect your time, enhance your ability to provide robust care, and simplify your workflow so you can focus on what matters most.

How do you pick the right EHR for your practice?

Not all EHR systems are the same, and this is important to remember when choosing the best EHR for therapists. The best way to find one that works for you is to make sure that it is specifically designed for mental health care. Some things they should include are:

• Specialized and fully customizable documentation templates for progress notes
• Integrated assessment tools to track patient progress over time (which supports evidence-based care)
• The ability to design, monitor and keep track of progress through personalized treatment plans with clear goals
• Integrated billing and revenue cycle management to streamline your financial process
• Scheduling and appointment management support for online booking, automated reminders and other necessities
• A secure, user-friendly client portal to enhance engagement and allow clients to complete intake forms, schedule appointments, communicate with their provider and pay bills
• Customizable dashboards and reporting tools for clear insights into clinical outcomes, finances and compliance metrics
• Integrated telehealth features for secure video conferencing
• A HIPAA-compliant EHR that offers robust security features (like end-to-end encryption and audit trails)
• An intuitive, easy-to-use interface that works across various devices

When choosing the right EHR software for your practice, be sure that it has a proven track record for mental health providers and offers ongoing support. Scalability is another important feature, so make sure it can grow with your practice and support any new locations if you decide to open them. This way, you'll know you won't encounter any service issues.

Before migrating systems, it's important to thoroughly plan your move. This way, you can have a smooth transition without sacrificing the quality of your patient care and HIPAA compliance.

Planning and assessment

Think about what you want to get out of this transition. If you run a practice, put together a transition team and determine what is and isn't working in your current setup.

Check that the new system has a good track record and customer support and can meet your needs. Your plan should have a defined timetable and roles and responsibilities for everyone in your team.

Data preparation and strategy

Carefully go through your existing data and clean it up by removing duplicates, standardizing formats and correcting outdated entries. As you plan to move this information, decide what you should focus on first. This usually includes active patient information and your recent notes. After this step is completed, decide which data can be securely archived. Make sure to work closely with your vendor to ensure accurate transfer of data and your informational display. Before you start moving, make sure to back up everything first.

Conclusion: The next generation of mental health EHRs

Remember, AI is meant to be a clinical tool, not a replacement for you. The best form of care is "hands-on" care. When used to your advantage, EHRs with built-in AI capabilities can support a more focused and human-centered model of healthcare. This way, technology handles the routine and day-to-day tasks so you can focus on your clients.

Upheal can help you discover the right solutions that transform your existing clinical workflow into the intelligent, interconnected system you deserve as a mental healthcare provider.

Choosing the right AI-enabled EHR can help your practice in an increasingly complex healthcare environment. Learn more about Upheal's pricing and plan options or check our blog to read more about the latest mental health care news and insights.