Last week I attended a continuing education workshop for psychologists at my local chapter of the Florida Psychological Association. Psychological Records: Basic Requirements and the (Forced?) Choice of EMRs was presented by Robert J. Porter, Ph.D., president of the Tampa Bay chapter and treasurer of Florida Psychological Association. Dr. Porter’s presentation was attended by about 30 psychologists and other mental health providers. The last FPA workshop on EMRs that I attended was over 10 years ago, and it was given by me. There were about five psychologists present at that workshop.
The difference in attendance speaks to multiple issues. First, Dr. Porter is an excellent presenter who talked broadly about EMRs. His years as a researcher and university professor combined with recent years in private practice give him great credibility. Secondly, the EMR landscape has changed hugely in the past decade with government requirements to migrate patient records to an EMR a distinct possibility.
The psychologists who are my age peers who used an EMR loved computers and liked doing all their work there. Most of our age-mates would never have considered keeping records that could not be locked up in a file cabinet behind their locked office door. The younger psychologists who are now replacing us in the private practice community are not only willing to consider keeping their records electronically. . . they are willing to keep them online using a Software as a Service (SaaS) type product. The move from needing to hold the patient record in my hot little hands to allowing it to float out there in the cloud is a sea change.
While Dr. Porter presented a great deal of information in the two hours he spoke, there were several items I thought you might find interesting.
- The American Psychological Association published Record Keeping Guidelines in the December 2007 issue of the American Psychologist. If you are a psychologist and you keep records, you should read them. If you keep behavioral health records but are not a psychologist, you might take a look at them. Such Guidelines frequently become part of the standard of care in a professional community.
- The APA Guidelines recommend disclosure to the patient of your record keeping procedures, including the limitations of confidentiality of the records. Those limitations of confidentiality lead to a likely need to maintain a separate record of care for each person you treat, including for each individual member of a family or couple. (Guideline 4)
- Ofer Zur, Ph.D., a licensed psychologist in California, offers extensive information about and continuing education on record keeping and many other aspects of behavioral health practice. [Retrieved 4/19/2011 from http://www.zurinstitute.com/recordkeepingguidelines.html.]
- Dr. Zur points out that a treatment plan usually includes problems or symptoms, a diagnosis, goals of treatment, interventions to be used to achieve the goals, and the rationale for use of those interventions.
I would add a quick note about the possibility of a requirement to keep records of psychological care in an EMR. At present, the only behavioral health providers who are Eligible Providers (EP) for ARRA funding to purchase an EMR are psychiatrists and nurse practitioners. Psychologists, social workers, mental health counselors and addiction professionals do not qualify, nor do psychiatric hospitals. While this may change, there is currenly no way for most mental health providers to obtain stimulus funds. At the same time, there is no requirement for them to move to an EMR, nor will they be penalized for not doing so (psychiatrists and nurse practitioners may be subjected to Medicare withholds). Fortunately, most of the products aimed at the private mental health practitioner are relatively inexpensive and can easily be obtained without resorting to government funding or a second mortgage on your house.
While an electronic medical record can be a powerful way to significantly increase the quality of the records maintained by you and your organization, you must know what you are required to maintain in the record. . . by the governmental jurisdictions and the professional guidelines to which you are subject.
How does your organization determine what goes in the client’s record? Who is responsible for those records? Are you using an EMR, a paper record, or some hybrid system?
Please share your thoughts on records in the Comments below.