In the realm of psychiatric hospitals and community behavioral health providers, Electronic Health Records (EHRs) play a pivotal role in delivering quality care while ensuring compliance with accreditation and regulatory standards. These facilities handle sensitive patient information while providing specialized mental health and substance abuse services. Consequently, optimizing electronic health records becomes paramount for meeting the unique requirements of this important health care space.

Optimizing Electronic Healthcare Records – Understanding the Landscape

Psychiatric hospitals and community behavioral health care providers operate within a framework of accreditation and regulatory requirements set forth by organizations such as TJC, DNV, CHIQ, ACHC, CARF, COA, CMS, SAMHSA, and state health departments. Compliance with these standards is essential for ensuring patient safety, confidentiality, and quality of care.

Tailoring EHRs for Psychiatric and Behavioral Health Settings

1) Comprehensive Assessment Tools and Treatment Planning

Customizing EHR templates to include comprehensive assessment tools specific to psychiatric and behavioral health conditions is just the beginning. Integrating these tools in order to structure staff for successful compliance is critical. For example, these tools should facilitate the documentation of psychiatric evaluations, risk assessments, and treatment plans in compliance with accreditation and regulatory requirements. This is accomplished through cueing staff to integrate findings and interventions to paint a realistic picture on an ongoing basis of the status of the individual served. Links between substantiated diagnosis, assessment findings, problem identification, relevant goals and interventions is critical. Like reading a biography and not a mystery novel, the reader of the clinical record should be able to follow the individual’s course of care and response to treatment. Trying to figure out how it all ties together is a recipe for a bad outcome. 

2) Suicidality and Risk Management

Incorporating specialized features within EHR systems to assess and manage suicidality and risk is imperative. Suicide risk screening, assessments, safety plans, and documentation of interventions should be seamlessly integrated into the workflow to ensure compliance with safety standards, accreditation standards, and regulatory requirements. Equipping staff with user-friendly tools that ensure compliance is essential. For instance, proximity monitoring on smart devices coupled with visual and auditory alerts as monitoring benchmarks can bolster safety measures. Additionally, interfacing monitoring software with EHR enables real-time integration, facilitating immediate communication between interdisciplinary teams and enhancing patient care coordination.

3) Medication Management and Monitoring

EHR systems should facilitate robust medication management and monitoring processes. This includes features for electronic prescribing, medication reconciliation, adverse drug event reporting, and monitoring of psychotropic medications. For example,

Integration with prescription drug monitoring programs enhances medication safety and compliance with accreditation and regulatory guidelines. For example,

• Use features such as drug-drug interaction checking with staff alerts to safeguard patient safety.
• Implement bar-coding apps integrated with the EHR to streamline medication management processes and reduce medication errors.
• Optimize performance improvement by utilizing EHR systems to maintain detailed audit trails of medication-related activities, including prescribing, dispensing, administration, and documentation.

These audit trails facilitate retrospective analysis, quality improvement initiatives, and compliance reporting to regulatory agencies and accreditation bodies. The ISMP Guidelines | Institute for Safe Medication Practices (ismp.org) is an excellent resource to assist organizations to build safe medication systems into their EHR.

4) Confidentiality and Privacy Protections

Ensuring the confidentiality and privacy of patient information is paramount in psychiatric and behavioral health settings. EHR systems should incorporate stringent security measures such as role-based access controls, encryption of sensitive data, and audit trails to track access to patient records. Moreover, compliance with HIPAA and state privacy laws is essential.

5) Interdisciplinary Collaboration

Facilitating interdisciplinary collaboration is paramount for delivering comprehensive care in psychiatric and behavioral health settings. EHR systems play a pivotal role in supporting communication and information sharing among various healthcare professionals. This includes psychiatrists, psychologists, social workers, nurses, mental health techs, peer support staff and others involved in care. It’s imperative to address any resistance or reluctance from providers regarding the integrated electronic document system. Succumbing to such resistance risks undermining the numerous benefits offered by the EHR system. Collaborate with your EHR vendor to optimize workflows by conducting click counts, ensuring that interdisciplinary care coordination is achieved with minimal clicks. The fewer the clicks required, the more likely staff members are to adhere to established workflows. Implementing hard stops in areas of recurrent non-compliance can help remedy the situation when necessary. This proactive approach promotes efficient communication, seamless collaboration, and ultimately, enhances the quality of care, treatment and services.

Continuous Compliance and Improvement

Optimizing EHRs for psychiatric hospitals and community behavioral health care providers is an ongoing process that requires vigilance and adaptability. Regular audits, staff training, and updates to EHR systems are essential to address compliance gaps and emerging accreditation and regulatory requirements. By prioritizing EHR optimization, psychiatric facilities and behavioral health providers can navigate accreditation processes effectively while delivering compassionate and high-quality care to the individuals they serve.

Barrins and Associates

Barrins can assist your organization to optimize your EHR to meet the unique needs of the population you serve. We also share our resources on best practices and strategies for efficiently and effectively developing and implementing user-friendly workflows to maximize the adaptability and effectiveness of your selected EHR system.

Barrins & Associates – “Guiding Your Success: Real-World Solutions to Meet accreditation and/or regulatory challenges”