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EMR Requirements for Substance Abuse

Electronic medical records systems are systems used to digitally collect and keep patient records on file. They are directly defined as electronic records of health-related information that may be gathered, managed, created, and consulted by authorized staff and clinicians within one health care organization by the Agency for Healthcare Research and Quality.

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These systems make it easier to provide high-quality care to patients and to encourage better patient safety. Perhaps surprisingly, the adoption of EMRs within the United States is not as high as in some other countries. It’s believed that only around 13% of all ambulatory physicians even have a basic system.

There are barriers to adopting electronic health records, such as the high initial cost of implementation or an insufficient return on investment, but with newer EMR systems, these issues are largely eliminated. Sound EMR systems will provide benefits that are much needed in a clinical setting, such as:

  • Assistance with patient scheduling
  • Offering standards-based electronic data storage
  • Offering computerized decision-support systems that prevent drug interactions when prescribing new medications for a patient
  • Access to past and new tests across multiple care settings
  • Giving access to patient information, including allergies, lab results, medications, and diagnoses

EMR systems help secure electronic communications between providers and patients. They are also HIPAA-compliant, securing information to prevent leaks.

A patient’s electronic health record contains information about their health history, so being able to share this with the appropriate physicians and clinicians is essential. Automatically updating the system between visits makes an EMR system indispensable and helps to mitigate any risks.

EMR Requirements for Substance Abuse Disorder Patients

Using Sunwaves EMRs as Unified Treatment Platforms for substance abuse disorder patients creates a scenario where their treatments and diagnoses can be easily managed and tracked. With the introduction of the Affordable Care Act, healthcare systems were encouraged to integrate both behavioral health and medical healthcare services. Clinics and hospital systems were also encouraged to use electronic medical records to improve the quality of care and information exchange about a patient.

Part of the reason why EMR use with substance abuse disorder patients is so important is to keep track of their treatments and to collect data on implementing behavioral healthcare. Good EMR records may also help prevent health risks in those with high-risk conditions.

With electronic health records, each provider has an opportunity to see the medications a patient takes, past diagnoses, tests, and more. What this does for the patient is undeniably important: It allows physicians and clinicians to double-check each other’s work and to make sure the patient is really receiving all the care they need. With good records, it may be possible to identify risk factors for a substance use disorder or to address medications that may not be working well enough to treat conditions like anxiety or depression that may lead to a SUD in the future.

With thorough records, it’s also possible to track a patient’s SUD over time, making it easier to see if treatments are working or if the treatment plan needs to be adjusted to help them improve the opportunity for a good outcome.

EHR Confidentiality Requirements for SUD Patients

Does federal law protect a SUD patient’s confidentiality regarding drug or alcohol abuse or if this information may be included in the electronic health information exchange system? Federal laws enacted around three decades ago recognized that some patients may refuse to seek treatment because they would be concerned about their information being shared widely on a health information exchange (HIE) system. However, despite that, the government does allow patient information to be disclosed to Health Information Organizations and HIE systems. There are requirements specifically set for substance abuse treatment programs, though, such as a requirement to get patient consent for disclosures.

The importance of the federal law isn’t solely related to concerns about sharing patient information between clinicians. Another issue is the risk of disclosing the patient’s SUD history in administrative settings or during criminal hearings. This is why organizations such as substance abuse treatment programs may need to abide by Part 2 of Title 42 of the Code of Federal Regulations, which controls the confidentiality of SUD patient records.

Why Use EHR/EMR in the Behavioral Health Field?

Electronic health records and electronic medical records are helpful in the behavioral health field for several reasons. These useful tools improve efficiency and healthcare practices by creating a better experience for everyone involved in a patient’s care.

A useful EHR program will have an integrated billing system, gather data on a patient’s history, offer clinical charting, store documents, and allow for reporting. Telehealth is also now included as a part of some EHR programs, such as Sunwave Health’s platform for SUD treatment providers and behavioral health.

Some of the reasons to use EHR/EMR platforms in the clinical setting are because they:

  • Improve patient record security by creating electronic documents that are automatically organized and stored. When the information is shared, only those with authorization can access the documents.
  • Make sharing patient information faster and easier. This improves communication between professionals as well as different departments so that a patient’s care is always up-to-date in the system. For example, a therapist may include information that updates the patient’s file, and their general physician may make changes to medications or information that is then updated for the therapist. This makes it easier for the professionals to work together to provide the best patient care.
  • Are more accessible. Unlike paper files, electronic files can be accessed from almost anywhere a person can get cell or internet service. This is particularly important to SUD and behavioral health providers, as they can handle life-threatening emergencies, like suicide threats, anywhere. This improves the crisis response timeline and may help save more lives.
  • Offer streamlined billing options, so there are fewer errors. This also helps reduce the cost of front-office work, saving the provider time and money.

Choosing EHR Programs to Coordinate Treatment

Coordinating treatment is essential in behavioral health when building customer relationships. Oftentimes, patients have not only mental health or substance abuse issues but also physical health concerns. This means that clinicians need to provide care in multiple settings, such as in therapy, a clinic, or a hospital.

According to the United States Surgeon General, using stronger EHR programs could improve care coordination, which would result in better substance abuse treatment. By communicating with this system to all of the patients’ supporters, it’s possible to improve outcomes.

For example, a psychiatrist may diagnose the patient with a dual diagnosis requiring inpatient treatment at a hospital. The hospital physician may then enter documentation that would need to be accessed by the primary care physician and psychiatrist for further treatment later on. On top of this, other clinicians, such as counselors or therapists, might need more information about the patient’s medical history to be able to support them during their SUD treatment protocol.

According to the Report on Alcohol, Drugs, and Health and the Surgeon General, only 20% of substance use disorder treatment programs were using EHRs in 2016. The goal of improving this number is to make sure that these clinics can more easily connect with social support systems and non-clinical systems needing to exchange patient information with them. Overall, the use of EHR stands to improve supportive care, monitoring, and engagement.