Electronic health records can greatly improve the clinical documentation in a psychiatric setting, according to a new article in American Health Information Management Association's Perspectives in Health Information Management.
Psychiatry has the lowest use of EHRs across 14 medical specialties, due to higher legal bars and confidentiality issues; additionally, the Meaningful Use program does not include most behavioral providers. The researchers, from the University of Southern California's Keck School of Medicine, evaluated the implementation of electronic charting in an adult public psychiatric outpatient clinic at a large public medical center.
To mitigate barriers and risks, the health system held meetings with administrators, clinicians and IT personnel. It also reviewed, among other things, state mental health laws and risk management experts. The organization developed a user-friendly electronic charting program, designing its own psychiatric electronic templates and modifying its quality improvement checklists, as there were no standard ones for psychiatry.
The researchers studied the documentation during the three years before and the three years after the July 2009 implementation of the electronic charting system. They found that electronic charting of psychiatric information improved the quality of clinical documentation. For instance, documented visit time and procedure code in intake notes improved from 60 percent to 100 percent compliance. Progress notes and medication monitoring notes also improved. The EHR use additionally increased the timely completion of medical records, corresponded with a positive continuous trend in quality improvement reviews and was a “valuable asset” for the training of psychiatrists.
“Quality documentation provides valuable and necessary information for ongoing assessment, continuing care, and continuity of treatment," the researchers concluded. "In this context, improvement in clinical documentation as found in this study will promote positive and promising effects in psychiatric services."