Many advantages are associated with incorporating EHR systems into one’s practice.

Mary Karapetian Alvord, PhD
malvord@alvordbaker.com
@drmalvord

The Health Insurance Portability and Accountability Act (HIPAA), now considered the standard for mental health practice, was established, in part, to improve: (a) portability of health care insurance, (b) continuity within and among health records, and (c) easier access to patients’ records.  HIPAA also requires the protection of privacy and careful monitoring of Protected (Personal) Health Information (PHI).  The Health Information Technology for Economic and Clinical Health Act (HITECH) was passed with the goal of promoting (and funding) a move from paper-based records to electronic records (EHR’s) that are “interoperable” (http://www.apapracticecentral.org/advocacy/technology/index.aspx).

The ultimate goal is to support a secure national exchange of records among patients, health professionals, and organizations.  Although professional psychology has advocated for full inclusion of psychologists under the Act’s financial incentive programs, this has not occurred.  A series of bills have been introduced to include psychologists as “meaningful users” who could qualify for financial support to establish an EHR system (http://www.apapracticecentral.org/update/2013/12-19/technology-bill.aspx).

The HIPAA and HITECH directives to make health records more portable and to facilitate communication among health care providers has resulted in practitioners and health-care institutions moving to establish Electronic Health Record-keeping (EHR) systems.  Advances in technology, including affordable hardware, software and increased Internet speed, help make performing this task more cost-effective.  This applies especially to small practices and solo practitioners.  Many advantages are associated with incorporating EHR systems into one’s practice.  The measurement of treatment outcomes is improved as is overall office efficiency.

Five Advantages of Electronic vs. Paper Records:

• Access. Digital records are easy to access, whether from the office or from a remote site. For example, a practitioner may work from two or more offices or locations; therefore, it is not necessary to carry paper files from one location to another. Information may be instantly accessed by logging into the secured system. Many practitioners appreciate the convenience of being able to see patients in the office or clinic and then write notes or reports from their home or from another (remote) location.
• Ease of use and legibility. The practitioner can dictate or type notes into an EHR system; for example, practitioners can save time by copying and pasting repetitive information. The EHR system allows easier access to authorized professionals and provides the system administrator with control over who may access specific information.
• Continuity of care with accurate information. Digital records provide for efficient exchange of information in transfers from one provider to another or among multiple providers and with transitions and moves. For example, within a hospital system, group practice or consortium, a patient seen in one department can have records transferred from another department so that medications, testing and/or other services, do not duplicate or interfere with services already rendered. If a patient is transferred or requires emergency care while his or her psychologist is away, the digital record can be easily transferred.
• Space Saver. Some of us regularly serve children and adolescents and are required by law to keep records for long periods of time (up to 25 years or more). Others regularly administer test batteries which, in the past, have resulted in huge physical files and large storage/retrieval costs. With high-speed scanners it is possible to digitize records to free up physical space previously required for paper records making it possible to readily retrieve both active and inactive files.
• Consistency of information. The use of templates, especially in those cases for which legally mandated minimum information is required, aids in keeping records consistent.

State-Specific Record-Keeping Templates

In 2012, Divisions 31 (States) and 42 (Independent Practice) were awarded a CODAPAR grant.   The grant’s goal was to develop and standardize templates to adhere to minimum record-keeping legal requirements specified by state and federal laws as well as the APA Ethics code.  Drs. Andrew Benjamin and Jeff Younggren chaired the task force organized to provide input from practitioners who were already using EHR’s in their work setting.  The FREE templates are now available on APA Communities for all APA members, organized by State.

Each State folder includes five documents: State Record Keeping Document, State Record Keeping Laws, State Intake Form, State Progress Note, and State Termination Summary.  To access this valuable information and templates go to www.apacommunities.org  and use your MyAPA login (free to register).  This will bring up your personal communities page.  On the left side bar note My Neighborhood and click GROUPS.  Choose Division 31 Ethics resources for (your state).

Resources

Devereux, R.L., & Gottlieb, M.C. (2012). Record keeping in the cloud:  Ethical considerations. Professional Psychology:  Research and Practice, 43, 627-632.

Drogan, E.Y., Connell, M., Foote, W.E., & Sturm, C.A. (2010).  The American Psychological Association’s revised “Record Keeping Guidelines”:  Implications for the practitioner.  Professional Psychology: Research and Practice, 41, 236-243.

Steinfeld, B.I., & Keyes, J.A. (2011).  Electronic medical records in a multidisciplinary health care setting:  A clinical perspective. Professional Psychology:  Research and Practice, 42, 426-432.