Do psychotherapists need to use EMRs or EHRs for writing clinical notes?
The short answer is, “no.” Not yet. And maybe-not-ever. There are other (better) tools psychotherapists can use for writing clinical notes and documenting medical necessity.
To understand the answer, it’s necessary to understand what they are, their purpose, and the differences between them. (Keep reading for an alternative to all of these!)
What’s the difference between EMRs, EHRs, and online programs?
An Electronic Medical Record or EMR is the same as as an Electronic Health Record or EHR. From here on out, I will refer to both as EMR. An EMR is designed for providers who practice in the same health care system, so that they can easily communicate with each other. All hospitals, agencies and large group practices are required to use an EMR when documenting medical necessity. When the providers are all at the same hospital, agency or large group practice, an EMR makes clinical and economic sense because EMRs facilitate coordination and continuity of care for patients/clients. These aren’t useful for private practice therapists.
“Online” programs marketed to private practice therapists are not EMRs. There are some good online programs for writing clinical notes, but calling them an Electronic Health Record is misleading. Yes, it’s electronic, and yes, it’s a health record, but they don’t have the same capability of communicating across an agency or among providers like EMRs.
Online programs capitalize on therapists’ fear of being out of compliance with a “requirement” that has been postponed multiple times and shows no promise of being instituted soon and possibly ever. The reason the implementation of an electronic medical record has been postponed is due to the complexity and cost of developing and implementing the technology. In fact, it is so costly, that NASW MA, has been advocating that private practice therapists be excluded from the EMR and EHR “requirement.” When and if the technology for all programs to communicate with each other will be developed is any body’s guess.
Remember, what is being marketed on the internet are ONLINE PROGRAMS — not EMRs.
Advantages of Online Programs for Writing Clinical Notes
- They can be quick and easy.
- Some include billing capability.
- Some include scheduling options.
If you want these options, an online program may be a good choice.
Disadvantages of Online Programs for Writing Clinical Notes
- They cannot communicate with other independent providers within the system because there is only one provider in the system, the private practice therapist.
- They are not interconnected with other online programs so they cannot communicate with providers outside their system.
- Online documentation programs that are designed as point and click products, produce boiler plate treatment plans and progress notes. In other words, click on a diagnosis, up pops the symptoms. Click on the symptoms, up pops a choice of goals. Then click on the goals, up pops a choice of objectives. Click on the objective, up pops interventions. They are not written to describe a specific client. Instead, they are written for a diagnosis. Believe it or not, insurance companies want treatment plans and session notes that describe our clients, not the diagnosis. So, they don’t like these boiler plate templates. (If you decide to use an online program, find one that does not fit this profile.)
- Anything on the internet can be hacked. This makes paper forms or forms you store in your personal password protected computer and encrypted program safer than those stored in the cloud or online.
- Because they are purchased as a monthly subscription, they are costly in the long run. The overhead of psychotherapists continues to rise faster than our income.
Paper Forms versus EMRs and Online Programs
Now that you know all about EMRs and online programs, let’s talk about the safer and less costly alternative for writing clinical notes: paper forms. To be transparent, I developed and sell paper forms so you might say I am biased. But I have used an EMR, an online program, and my own paper templates.
My forms address all of the disadvantages of online programs.
- They contribute to clinical thinking.
- My forms pass audits and fulfill the legal requirements.
- They cannot be hacked and preserve client confidentiality.
- My forms can be completely customized to fit the practice needs of the therapist.
- They are a one-time cost, making them less expensive than a subscription service.
The bottom line for me is – I will not get an online program unless and until it is a hard and fast requirement. From the information I currently have, that day may never come.
I know that writing clinical notes can feel like an exercise in annoyance. That’s why I also offer workshops to teach you how to translate your clinical intuition into a logical, insurance-friendly review of treatment. You’ll learn how to not waste your time writing notes and know exactly how much to write and what to include, and walk away with a clear understanding of what to do while feeling confident in your abilities.
If you want more information about paper forms and templates as well as information on how to do your documentation so you pass an audit, maintain client confidentiality, and reduce the risk of legal nightmares, please contact me.