Effective Integration of Behavioral Information into the EHR Necessary to Improve Patient Care

Patient CareElectronic health records (EHRs) provide clinicians with the information they need to make decisions affecting an individual’s health. Behavioral medicine transcription service providers meet the documentation requirements of behavioral medicine staff, psychiatrists, psychologists, clinical nurse specialists, mental health clinicians, and clinical social workers. However, what’s important is including behavioral health data within the patient record. Clinicians would find it easier to provide comprehensive care only if they have as much information as possible about their patients. According to a Physicians Practice report published in November 2016, this is a challenge for physicians as, traditionally, behavioral health information has been maintained separately from the medical record that stores data about the patient’s physical health.

A recent study in the Journal of the American Medical Informatics Association (JAMIA) looked into missing clinical and behavioral health data in primary care EHR technology. The researchers found that the lack of integration, interoperability, and exchange in US health care led a major EHR to miss behavioral health data as well as information resulting from patient visits to specialty care providers. The study reported that “nearly 90% of acute psychiatric services at hospital facilities, representing more severe exacerbation of mental illness, were not captured in the EHR”.

The researchers point out that physician could not use EHRs effectively unless non-primary care patient health data, especially behavioral health information, is included. The main issues that stand in the way of bridging the gap between behavioral health and EHRs are:

  • Getting physicians and patients to understand the importance of including behavioral health data within the patient record
  • Psychiatric evaluation and management notes, case management notes, clinical intake narratives, treatment plans, and other unstructured data are not easy to analyze in a traditional EHR view.
  • According to a Health IT report, behavioral health organizations have not adopted EHRs due to lack of qualified IT and project management support.
  • Concerns about patient safety and privacy laws restrict EHR use by behavioral health entities.
  • Ineligibility for the Medicare and Medicaid Incentive Payment Program is a barrier to the adoption of health IT by mental health professionals.

One way physicians can address the problem is to explain to patients that including their behavioral health information in their patient record will improve care. The Physicians’ Practice report mentions the case of a geriatrician who works along with a clinical social worker to ensure that patients’ records include behavioral health data. The social worker makes handwritten notes during the psycho-social assessment with the patient’s permission and the physician subsequently enters the data in the EHR.

Recent reports indicate that manufacturers of healthcare data platforms are coming out with solutions for the behavioral health industry to narrow the interoperability gap between primary care providers and behavioral health providers. US-based medical transcription outsourcing companies support these specialists in meeting their patient care goals with quality documentation solutions.