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The Advantage of Behavioral Health EHR for Addictions Professionals

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One of the specialty areas that have been slow to adopt electronic health records (EHR) is the addictions field. Part of the reason is that some addiction professionals, such as Licensed Clinical Social Workers and psychologists, are not eligible for incentive payments from the Centers for Medicare and Medicaid Services. The good news is that there is some movement in correcting this oversight. 

Additionally, addiction centers that employ physicians and licensed nurse practitioners can receive CMS incentive payments as long as their caseloads include at least 30 percent Medicaid patients. Participating in the CMS EHR incentive payment programs can offset a substantial part of the EHR software's entry cost.

The Advantages and Advances of Behavioral Health EHR

When addictions centers take advantage of the new behavioral health EHR Software as a Service (SaaS) packages, they significantly reduce the cost of ownership and increase the productivity of their practices in the following ways:

When using behavioral health EHR SaaS, the addiction center does not have to pay the price of servers and other hardware, which reduces the entry cost. Additionally, since SaaS is subscription-based, this EHR software can be easily scaled to meet the clinic's needs. This also reduces the cost of the software. 
With a behavioral health EHR, crucial updates are handled automatically, such as the upcoming changes to diagnostic codes with the release of DSM-V; multiple providers can enter notes simultaneously, making coordinating services easier and ensuring that documentation is entered promptly and accurately.

An H7 complaint behavioral health EHR allows the patient’s medical records from other providers, which is crucial when working with patients with prescription drug abuse problems.

It is also important to remember that many third-party payers and Medicare and Medicaid will require EHR to reimburse services.

This guide will share all the resources we’ve created to help you navigate choosing or switching your behavioral health EHR. Let’s dig in! 

Why Your Practice Needs Behavioral Health EHR Software

As a dedicated health professional, you want your focus to be on delivering the best care for your patients. Unfortunately, many behavioral health physicians are split between caring for patients and keeping track of billing, charts, and other critical records. Relying on manual record-keeping can easily result in a tangle of lost or misplaced records, incidences that can cost you time and cause headaches. An efficient electronic health record-keeping form can help solve many of these problems and make your practice more efficient.

Enter Behavioral Health EHR Software

EHR software from a reputable medical software company can help cut the knot, allowing your practice to run as smoothly and efficiently as possible. This software saves behavioral health physicians time and effort in tracking electronic health records. This makes it possible for physicians to accurately diagnose, treat and bill their patients without resorting to painstaking and sometimes-inaccurate record-keeping. Most behavioral health EHR software is cloud-based, hosted by trusted medical software companies that comply with HIPAA and other federal regulations that govern electronic health records. 

How EHR Can Help Your Practice

Behavioral health EHR software helps you maintain all your electronic health records efficiently and sensibly. This software can help your practice track detailed session notes, maintain access to an expanded medical history over extended periods, and maximize productivity and cash flow. Most EHR software geared towards behavioral practices offers many behavioral health forms. Physicians can also prescribe medications and schedule appointments online. Cloud-based EHR software also offloads the need for extensive IT support, which many practices need help to support.


Key Takeaways:

  • Behavioral health EHR software helps psychologists, psychiatrists, and other behavioral health physicians smoothly and efficiently manage their practices.
  • EHR software efficiently keeps track of electronic health records, patient billing, prescriptions, and scheduling.
  • EHR software eliminates inaccurate record-keeping that can cause problems within the practice.
  • And even more, cloud-based EHR software eliminates the need for in-house IT infrastructure while conforming to HIPAA and other regulations.

Why Your Behavioral Health Practice Needs Specialty-Specific Practice Management Software

On any given day at a behavioral health clinic, the staff may be called upon to serve patients and family members similarly to any other medical practice. They greet clients arriving for appointments, verify insurance coverage and personal contact information, and escort them to comfortable exam or consultation rooms. Depending on the nature of the visit, a nurse or medical assistant may take vital signs and update the patient record to ensure the file is up-to-date and accurate.

However, caring for 25% of Americans with mental health disorders is often more complex than providing primary care.

For example, many people passing through a behavioral health practice also have underlying medical conditions and socioeconomic determinants contributing to low compliance rates. Staff must screen for signs and symptoms, indicating that team-based care is necessary. A survey of more than 6500 primary care physicians revealed that 50%-90% of patients referred for external BH services never receive treatment – often because the patient never initiates service.

Finding a better model of integrating medical care and BH services is critical for the mental health population. Numerous studies confirm medical outcomes improve for patients with chronic and acute diseases when effective mental health and substance abuse treatment is delivered in conjunction with primary care services. The challenge is finding solutions that improve care delivery processes while addressing financial and organizational barriers. Behavioral Health Practice Management software may be the key to enhancing service delivery and patient outcomes.

🎥 Watch how MedicsPremier PM Software can increase your efficiency while reducing costs.

What is Behavioral Health Practice Management Software?

Practice management (PM) software allows administrators to strengthen the service delivery model by exploring workflow patterns and initiating more efficient, more effective processes. The organization can better serve its clients by identifying the needs of each patient, patient group, and individual team member.

For BH practices, better services may include developing policies that create same-day appointments for external referrals, initiating insurance pre-authorization protocol, or providing acute stabilization solutions for clients waiting to see a preferred mental health specialist. PM software also gives behavioral mental health clinic administrators the tools to assess staff skills and knowledge gaps.

Extracting data within the EHR via PM software report generation tools provides ample information to determine if your team could do better for your clients by offering secure, digital appointment scheduling, pre-visit and post-visit follow-up calls or more rigorous screening techniques.

Behavioral Health Practice Management software tracks every touch point in the patient flow from the first telephone call or referral through scheduling, coding, billing, and service reimbursement. Armed with this information, your organization can address weaknesses in your service delivery model and implement changes that make your clinic operate more efficiently, often resulting in higher profit margins and better patient outcomes.

Which Specialty-Specific BH Software Is Right For Your Organization?

Mental health professionals are more involved with local law enforcement, social service agencies, and community outreach facilities than other specialty medical providers. The unique community engagement levels and diverse types of clients seen can make choosing BH software challenging. Every practice is different and has its rhythm and resources. Some psychologists only offer outpatient services, while others may focus on inpatient care. Partial inpatient treatment plans are vastly different than outpatient services.

There are also unique coding guidelines for psychiatric care, counseling sessions, substance abuse programs, and prescription monitoring services. If your clinic also provides virtual office visits, another set of billing codes and insurance concerns must be addressed.

These needs are easier to manage with customizable BH practice management software.

Are There Benefits to Using Specialty-Specific Behavioral Health Practice Management Software?

An ideal PM solution allows clinicians, counselors, and other medical team members to identify the diagnostic codes and modifiers used most frequently in your particular medical business model, facilitating faster coding and claims filing tasks.

Whether your practice serves juveniles with conduct disorders and ADHD or you primarily serve adult patients with schizophrenia who require recurrent hospitalization, your staff shouldn't have to wade through hundreds of ICD-10 or DSM-5 codes to find the appropriate diagnostic label. When codes are used appropriately, fewer denied and pending claims improve cash flow. With fewer claims requiring additional internal review, staff members can focus more on patient-facing services.

While each practice will benefit from PM software differently based on their unique needs, there are five key benefits of implementing specialty-specific PM solutions that are nearly universal. They are:

  • Time-saving features that reduce clicks and improve accuracy.
  • Digital files reduce physical storage requirements, allowing space to add another conference room or treatment area without investing in remodeling or major construction.
  • Functionality that supports Meaningful Use reporting and coding compliance.
  • Automation, including secure digital billing, that positively impacts revenue streams and office productivity.
  • User-friendly scheduling modules that instantly share appointments among the team, facilitating parallel appointment scheduling and other ancillary services at the most cost-effective time for the clinic and the most convenient time for the client.
  • Key Features of an Ideal BH Practice Management Software Package
  • The information in your EHR provides valuable clues that will help you map your current workflow. Adding Behavioral Health Practice Management software with custom report generation capabilities to the mix gives your organization the granular data you need to fine-tune your organization's processes and procedures.

While your staff uses fewer keystrokes and clicks to update the digital files, automation allows them to eliminate – or dramatically reduce – the amount of time previously spent rifling through paper files, verbally managing referrals, and preparing handwritten prescriptions. Indexed, searchable files make finding information in the system faster, providing scanned documents are abstracted properly.


As mentioned earlier, scheduling is faster if your BH practice exploits built-in scheduling tools. In addition to allowing instant sharing across all departments within your organization, which may help you capture more revenue more efficiently, your staff can define appointment types that fit your patient population, schedule private and group therapy sessions, and even set up alerts for missed appointments, allowing you to quickly see which patients, or patient groups, consistently fail to show up for appointments. These alerts may signal weaknesses in your schedule confirmation process or indicate which patients would be more compliant with automated text or voice reminders about their upcoming visit.

While shaving off several minutes of processing time for every claim can add hundreds or thousands of spendable dollars to the practice's coffers annually, confirming insurance coverage before providing services can improve revenue capture in real-time.

Electronic claim submission features that allow simultaneous submissions to multiple insurance providers, reduce errors and expedite faster payment from all third-party sources. These features and claim denial manager notifications alert processors to potential errors before filing the claim, saving your accounting team time and money.

Finally, customized reporting increases visibility and supports corrective actions that lead to positive changes within your practice – changes that will improve patient care and drive an organization-wide evolution from a work environment to a patient-centric, lean organization that performs like a Swiss timepiece. Detailed reports allow you to review patient status, financial reports, claims in progress, and patient population data your organization needs to meet your goals and best serve your clients.

Managing a successful Behavioral Health Practice is unlike running any other medical service organization.

Few people will fail to see an orthopedic surgeon if they know they have a broken femur or suspect a hip joint is failing. However, many people suffer silently from mental health disorders because they fear stigma or face cultural barriers to seeking care. Serving this unique population demands a lean, strong medical organization that can guide them through their medical journey. Implementing best-fit, customizable specialty-specific practice management software will help your team increase internal efficiency and productivity while improving overall patient care. Here are the key points to remember when exploring software solutions for your clinic or practice.

Conclusion: An ideal BH practice management software package:

  • Provides opportunities to save time creating, updating and maintaining digital patient records
  • Utilizes automation features that save valuable time and money
  • Includes electronic claims processing modules that allow your practice to file claim with multiple payers simultaneously
  • Features must support workflow mapping and process analysis for all patient touch-points
  • Has scheduling modules that allow interdepartmental sharing, and preferably missed appointment alerts and automated appointment reminders across diverse channels like text, telephone, chat and patient portal email systems
  • Enables BH practices to maximize office space by reducing paper file storage and redesigning workflow patterns that relocate shared computer terminals to more convenient areas for all staff members
  • Improves cash flow by creating opportunities to capture self-pay and co-pay funds before visits
  • Incorporates insurance verification into the sign-in/reception phase and patient payments into the follow-up appointment schedule and exit interactions

Your Behavioral Health Practice has its own unique patient population and care delivery model. You need a specialty-specific Behavioral Health Practice Management software package tailored to your daily workload and the services you provide.

3 Things You Need in Behavioral Health EHR Software

While behavioral health providers have been reluctant to adopt behavioral health electronic health records (EHR), the reality is that they face reductions in Medicare and Medicaid reimbursements if their practice does not adopt EHR by 2015 has motivated behavioral health practitioners to consider their options in behavioral health EHR.

With the introduction of cloud-based EHR software with enhanced security features, the entry cost of behavioral health EHR has significantly decreased, and the protections for patient records have become more robust. Additionally, introducing specialty software explicitly designed for behavioral health providers reduces the need for costly and time-consuming customizations.

Key Features Needed in Behavioral Health EHR Software

The practice of psychiatry and other behavioral health disciplines has always had unique needs in terms of record and documentation, which is why one-size fits all EHR software solutions do not meet the needs of most behavioral health providers. Specialty EHR software for behavioral health practitioners offers these key features to meet the needs of psychiatrists and other mental health professionals. 

Fits the Workflow of Behavioral Health Practices

In most medical practices, patients see only one doctor on their visit. Patients that visit behavioral health centers often see their psychiatrist and a therapist in individual or group therapy. Behavioral health EHR software allows multiple practitioners to access patient records simultaneously, significantly decreasing the risk of misplaced progress notes since the practitioner can enter them during service.

Capability to Handle Different Document Requirements

Typically, the documentation requirements for services provided to children and adolescents differ significantly from those required of adult patients. A robust behavioral health software solution can handle the different types of documentation seamlessly.

Medication Tracking and Detailed Medication Management

Since many psychotropic medications, such as benzodiazepines and psychostimulants, are highly addictive and easily abused, it is essential to have detailed records tracking these prescriptions. Behavioral health software with e-prescribing capabilities ensures that the prescription is filled by the person for which it is prescribed.       

Behavioral health clinics of all sizes find they can increase productivity and decrease administrative costs when they start using behavioral health EHR. 

Key Takeaways:

  • The latest generation of behavioral health software addresses affordability and security concerns.
  •  Behavioral health EHR facilitates effective and efficient practice management.

🔍 Related Article: 5 Behavioral Health/Substance Use Disorder Trends to Be Aware of in 2023

5 Questions About Behavioral Health EHR You Should Be Asking

Now that your behavioral health practice is starting to take off and you are seeing more patients than ever before, you and your staff need to manage your organization’s growing pains. One of the first things medical organizations tend to do when their patient volume substantially increases is to check on software solutions. This is where behavioral health electronic health record software comes in.

Instead of trying to make do with a generic EHR application (or a paper-based system), successful practice owners will want to use specialized behavioral health software. Here are six questions that you should be asking about behavioral health EHR solutions.

1. Does it Include Speech and Handwriting Recognition?
Your doctors and nurses are already busy enough processing patients. They shouldn’t have to waste any more time when it comes to getting information into a patient’s electronic health record. 

This is why you should go with a vendor with speech recognition capability, letting your staffers simply speak and then see their words accurately transcribed on the screen. Handwriting recognition would also be good if older records need to be entered into the system.

2. What Common Behavioral Health Issues Appear as Options for Patient History?
When entering a patient’s medical history, there are a number of behavioral health topics you will find more convenient to add when they already exist as options in the software. 

This means you can quickly note details about a patient’s support systems or if there is any history of physical or mental abuse, for example. Details on a patient’s self-reported numbers for the Sadness Scale or whether there is a risk of suicide or violent outbursts directed toward others will also be easier to note.

3. Does it Come with DSM Code Capability?
You and your staff likely refer to the Diagnostic and Statistical Manual of Mental Disorders daily. You should select a behavioral health EHR that includes DSM code information.

4. What About E-prescriptions?
Verify that the behavioral health EHR you are considering adopting will include a feature to let your physicians and nurse practitioners create electronic prescriptions. In particular, the software should enable you to prescribe controlled substances since many mental health patients require these medications.

5. Are Treatment Plans Built In?
To make things easier for the staff and ensure that you have various options for treating patients, your behavioral health EHR should include them, along with details on potential problems, objectives, and goals for different intervention strategies.

When you determine that setting up a behavioral health EHR is the key to your practice’s ongoing success, you must find a reputable software provider with a proven track record of success. Then, you can get back to diagnosing and caring for your patients, devoting more time and attention to them than ever before.

Key Takeaways:

  • Selecting the most appropriate tool for your business is best. You should use a behavioral electronic health record application instead of a general EHR to help you manage patients.
  • Speech and handwriting recognition in your behavioral health EHR will make it easier for doctors and nurses to enter patient details.
  • Make sure the software provider includes DSM code capability.
  • Ideally, the software will let your doctors generate electronic prescriptions for patients requiring controlled substances to get better.

Features EHR Can Provide Behavioral Health Practices

As treating addictions and other psychiatric disorders become more complex, so does managing patient records in behavioral health practices. To compound the issue, the service delivery and documentation requirements differ among the third-party payers. Most behavioral health practices must adopt electronic health records to avoid liability issues and payment recoupments associated with missing or incomplete documentation.

The Benefits of EHR for Behavioral Health Providers

  1. Coordination of Services: Since a single patient in a behavioral health practice might receive various services from different providers within a clinic, EHR provides a means of tracking all services to ensure the documentation is in the patient's record and the billing reflects the services rendered. Additionally, the providers can view the patient's progress in other services, facilitating care coordination across services.
  2. Track Progress in Continuum of Care: Many behavioral health patients require hospitalization for stabilization. Others require partial stabilization services to function in the community. Electronic health records for behavioral health clinics allow the patient's treatment team to track interventions and the patient's response throughout the continuum of care without waiting weeks for medical records requests to be filled.
  3. Facilitate Audits and Surveys: The forms and fields of behavioral health EHR can be customized to meet the requirements of third-party payers, ensuring the documentation meets the insurer's standards. Additionally, EHR can show in a single screen if there is missing documentation, or the program can generate a report by the patient or provider. This saves significant administrative time and expense preparing for Medicaid and Medicare audits and accreditation surveys by JCAHO, COA, and CARF.
  4. Track Medication Administration: Since psychiatrists who prescribe certain psychotropic medications, such as psycho-stimulants and benzodiazepines, face a high degree of scrutiny from regulatory agencies, EHR provides a means of documenting prescriptions for medications, as well as information about the dispensing of these drugs.

The return on investment is substantial given the amount of administrative time saved by EHR and the decreased chance of penalties during audits.

Key Takeaways:

  • EHR is essential for effectively managing medical records in behavioral health practice.
  • EHR facilitates the coordination of care among the patient's treatment team.
  • Electronic health records save money through decreased administrative costs and recoupments from third-party providers.

What to Look for in a Mental Health EHR

Healthcare organizations that provide mental health services lag other specialty areas in adopting electronic health records (EHR). In 2006, less than 8 percent of the community mental health centers adopted EHR. While more mental providers have adopted EHR today, the percentage of professionals using this technology needs to be higher due to concerns about cost and difficulty in finding EHR software relevant to mental health practices. Fortunately, these concerns have been resolved with mental health EHR software now being offered on a subscription basis.

Features to Look for in a Mental Health EHR

Since mental health professionals now have options when selecting EHR for their practices, here are some questions to ask to find the best mental health EHR for your practice:

Does the Vendor Offer Support Services?

When looking for a mental health EHR, finding a vendor willing to work collaboratively to assist in planning and implementing the system is essential. Even when an EHR is explicitly created for a mental health practice, the software must be tailored to have the needed forms and fields the clinicians need. Additionally, the EHR vendor should offer training and support. 

Does the Mental Health EHR Fit with the Practice’s Clinical Model?

Since different mental health practices and agencies offer different services and work according to different clinical models, choosing an EHR with the encounter codes needed for the practice is essential. It is also vital to ensure it has the necessary forms and fields required by third-party payers and accreditation organizations.

Is the EHR Software Certified?

To qualify for the EHR incentive payments from the Centers for Medicare and Medicaid Services, eligible providers must attest that they are using ONC/CCHIT-certified software.

When looking for mental health EHR software, it is best to find a package designed especially for mental health practices to avoid issues with irrelevant fields and forms that can disrupt workflow. 


Key Takeaways

  • New options in mental health EHR have removed many of the barriers providers face when adopting and implementing this technology.
  • Check with the vendor to ensure that comprehensive support services are offered.
  • Verify that the EHR has the codes and documentation required for third-party payers. 

🔍 Related Articles: 10 Must-Have Features for Behavioral Health and Addiction Treatment EHR & PM Software

Using Behavioral Health EHR to Capture and Report Clinical Quality Measures

Most behavioral health providers are familiar with capturing and reporting clinical quality measures. CARF, COA, and the Joint Commission have required this data as part of the accreditation process. Clinical quality measures are the metrics used to measure the efficacy, efficiency, and safety of the services that patients receive from providers. As part of the Center for Medicare and Medicaid Services (CMS), behavioral providers must report several clinical quality measures to qualify for incentive payments.

While providers can report these metrics using the attestation process through 2013, in 2014, healthcare professionals mudrivest provide their clinical quality measures electronically through electronic health records (EHR).

The Categories of Clinical Quality Measurements for Behavioral Health

Some examples of the clinical quality measures that providers need to submit to CMS include the following: 

  • Metrics Related to the Treatment of Bipolar Disorder and Major Depressive Disorder: Behavioral health providers need to provide the results of suicide assessments, screenings for alcohol and other substance abuse, maternal depression screenings, and assessments for manic behaviors.
  • Data from Adolescent Risky Behavior Evaluations: Some behaviors that CMS considers “risky” for adolescents include sexual acting out, substance abuse, and aggression.
  • Documentation of Hospitalization Aftercare Services: Behavioral health patients often fall through the cracks after being discharged from inpatient services, often leading to the patient decompensating. To avoid this situation, CMS requires reports of outpatient follow-up after a patient has been released.

CMS is currently in the process of developing additional clinical quality measurements related to the treatment of emotional trauma, autism, suicide, and substance abuse disorders.  

The Benefits of Using Behavioral Health Specialty EHR

With behavioral health specialty EHR, the software captures the metrics behavioral health professionals need to report to CMS without customization. In addition to allowing behavioral health professionals to continue to be eligible for incentive payments, these metrics are captured for audit audits by accreditation authorities. This will make the accreditation survey process much less stressful and time-consuming for the behavioral health agency administration.

Key Takeaways

  • CMS has established specific clinical quality measurements that behavioral health providers must report.
  • Behavioral health EHR captures these clinical quality measures without customization.




Contact ADS for more information and to schedule a personalized overview on its MedicsCloud Suite or MedicsRCM for behavioral health and addiction disorders.

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