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How to Tell the Difference Between an EMR, EHR, or PHR

Many people use the terms electronic medical record (EMR), electronic health record (EHR), and personal health record (PHR) interchangeably. This can confuse patients, consumers, and even regulators.

Although an EMR, an EHR, and a PHR are very similar in practice, there are some differences in how the terms are used.

Similarities Among EMR, EHR, and PHR

The three acronyms are confusing mainly because the terms they represent already share many similarities:

These are all records—that is, collections or repositories of data—that contain health-related information
Like EMRs and EHRs, PHRs also can be stored electronically and managed by some type of software
Although only PHR has “personal” in its name, all three terms may involve information of a personal nature
Only two of the three terms use the word “health,” but all three are health-related.

Definition of Electronic Medical Record (EMR)

According to HealthIT.gov, an EMR is the digital version of the patient charts created by individual health facilities and providers. The data included in an EMR are primarily used to diagnose and treat a patient’s concern. Unlike paper charts, EMRs can help clinicians track and monitor data over time and identify patients with particular needs.

The biggest drawback to an EMR is that it is confined to a single provider. Traditionally, EMRs do not support interoperability or the exchange of information. While the EMR is an improvement over traditional paper charts, its failure to use standards-based interoperable data can fall short of “meaningful use.” A 2008 report by the National Alliance for Health Information Technology noted that the EMR term could become obsolete.

Definition of Electronic Health Record (EHR)

Like an EMR, an EHR is also a digital version of a patient’s chart. An EHR, however, includes data from all clinicians and facilities involved in a patient’s care. All authorized providers and staff can access this information to treat a patient.
Such information includes:

Diagnoses and allergies
Medications and other treatment plans
Immunization dates
Test results and radiology images
Provider contact information

The EHR follows the patient, and is not specific to a location. For example, an addiction treatment client may receive care from a family doctor, testing laboratory, psychiatrist, and substance abuse treatment clinic. Each of these providers would contribute that client’s data to the same EHR. This makes the EHR essential for data sharing and coordination of care.

Similarities Among EMR, EHR, and PHR

The three acronyms are confusing mainly because the terms they represent already share many similarities:

These are all records—that is, collections or repositories of data—that contain health-related information
Like EMRs and EHRs, PHRs also can be stored electronically and managed by some type of software
Although only PHR has “personal” in its name, all three terms may involve information of a personal nature
Only two of the three terms use the word “health,” but all three are health-related

According to HealthIT.gov, an EMR is the digital version of the patient charts created by individual health facilities and providers. The data included in an EMR are primarily used to diagnose and treat a patient’s concern. Unlike paper charts, EMRs can help clinicians track and monitor data over time and identify patients with particular needs.

The biggest drawback to an EMR is that it is confined to a single provider. Traditionally, EMRs do not support interoperability or the exchange of information. While the EMR is an improvement over traditional paper charts, its failure to use standards-based interoperable data could fall short of “meaningful use.” A 2008 report by the National Alliance for Health Information Technology noted that the EMR term could become obsolete.

Definition of Electronic Health Record (EHR)

Like an EMR, an EHR is also a digital version of a patient’s chart. An EHR, however, includes data from all clinicians and facilities involved in a patient’s care. All authorized providers and staff can access this information to treat a patient.
Such information includes:

Diagnoses and allergies
Medications and other treatment plans
Immunization dates
Test results and radiology images
Provider contact information

The EHR follows the patient, and is not specific to a location. For example, an addiction treatment client may receive care from a family doctor, testing laboratory, psychiatrist, and substance abuse treatment clinic. Each of these providers would contribute that client’s data to the same EHR. This makes the EHR essential for data sharing and coordination of care.

Definition of Personal Health Record (PHR)

What makes PHRs different from EMRs and EHRs is who controls it. Although the data kept within a PHR may come from an EHR, the patient is in charge of PHR management and access. This helps patients collect and manage their own health information in a private, and confidential environment.

Patients can enter information into their PHRs themselves, such as their lifestyle habits or over-the-counter medications. They also can add data from other sources, including home monitoring devices and additional care providers.

The above definitions of an EMR, EHR, and PHR are tied to the concepts of meaningful use and interoperability. As these ideas are refined and implemented, the definitions also may evolve.

An EHR to Support Both Providers and Patients in Behavioral Health and Addiction Treatment

BestNotes EHR solutions helps streamline your behavioral health practice and improve patient care. Contact us today and request a live demo to learn more about what we can do for you!

date:  Feb 06, 2019
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Idaho Addiction Treatment News Roundup: January 2019

From medication-assisted treatment (MAT) availability to opioid alternatives, there have been numerous recent stories and studies involving substance abuse and addiction treatment in Idaho. Here’s are the stories making headlines in the state in recent weeks.

Idaho Medical School Emphasizes Opioid Alternatives

Idaho College of Osteopathic Medicine in Meridian, the state’s first medical school, is working to reduce addiction by teaching its students about alternatives to opioids. This is part of the school’s emphasis on osteopathic principles and practices, which consider the whole person and all factors that may be contributing to disease or injury. Students who graduate from the college will have spent at least 200 hours in a learning lab, gaining hands-on experience in treating everyday issues with non-opioid techniques.

More Idaho Teens Struggling With Substance Abuse

The Idaho Youth Risk Behavior Survey found that more than 7,000 high school girls in Idaho used prescription drugs without a prescription in 2017. The study surveyed 1,818 high-school students from 53 public schools across Idaho.

Alexis Pearson, a treatment supervisor for the Treatment and Recovery Center in Twin Falls, noted that marijuana and alcohol use have been the main substance-abuse problems among students. Use of opioids and heroin, however, are beginning to catch up.

Children as young as 13 have sought help from the center, Pearson says. Many students who seek help often have parents who struggle with addiction.

Idaho Lacking in Medication-Assisted Treatment Facilities

Among those U.S. facilities that treat substance use disorders, only a small minority offer MAT, researchers have found. According to research published in the January issue of Health Affairs, Idaho has one of the lowest proportions (16.8 percent) of treatment facilities offering any FDA-approved medication. The study was conducted by researchers at the Johns Hopkins Bloomberg School of Public Health, who analyzed national survey data from 2007 to 2016.

Of those facilities that do offer MAT, only 6 percent offer all three FDA-approved medications. Ideally, facilities should offer all three medications (buprenorphine, naltrexone, and methadone), since patients may see different outcomes from different drugs.

Get the Best EHR for Addiction Treatment Providers in Idaho

Need to streamline your practice and improve patient outcomes? BestNotes EHR was created with you in mind!
Contact us today to learn more about an EHR and CRM solution developed specifically for behavioral health and addiction treatment providers.

date:  Jan 29, 2019
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How ICD-10 and DSM-V Work Together in an EHR

Behavioral health and addiction treatment providers face many complexities. Clients often present with a variety of concurrent conditions. Treatment plans may involve multiple providers recommending various long-term solutions. This can also make documentation and billing more complex for behavioral health and addiction treatment.

Additional complications come from the use of multiple documentation codes. This primarily includes ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) and DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition).

Use of Different Diagnostic Codes

ICD-10 was developed by the World Health Organization and is used by member states across the globe. The United States uses a modified version of ICD-10 to report and track diseases. Updating from ICD-9 to ICD-10, completed in 2015, was required for all U.S. entities under HIPAA rules.

While ICD-10 is a worldwide standard, DSM-V was created by the American Psychiatric Association. Primarily used among mental and behavioral health providers, DSM-V provides standard criteria for classifying mental disorders. The U.S. Centers for Medicare and Medicaid Services, however, still requires that behavioral health providers use ICD-10 designations to bill for services.

There is some overlap between the DSM-V and ICD-10, but because of their intended uses, and because ICD-10 is intended to be more comprehensive, many differences exist. For example, researchers have found discrepancies between the two systems when diagnosing mild and moderate cases of alcohol use disorder. For severe forms of alcoholism, the ICD-10 and DSM-V are more compatible.

How Diagnostic Codes Work in an EHR

The important thing to remember is that DSM-V helps clinicians diagnose behavioral health issues more accurately. In contrast, ICD-10 helps billing staff code and bill more accurately.

Because of these differences, a behavioral health provider’s EHR system should incorporate both types of coding. The two systems should coexist to help both clinicians and administrative staff.

The right EHR should:

Provide a library of all DSM-V categories and codes in an easy-to-search format
Help clinicians easily find diagnostic criteria to help create a treatment plan
Help users create goals and interventions appropriate for the diagnosis
Cross-reference DSM-V codes with the appropriate ICD-10 code

How does BestNotes measure up?

BestNotes EHR is designed to streamline your behavioral health and addiction treatment practice for the best patient outcomes and more efficient billing. BestNotes EHR solutions make it easier than ever for clinicians to create custom treatment plans.

With BestNotes, clinicians can:

Auto-populate criteria for a diagnosis and incorporate it into a treatment plan
Auto-populate customizable goals, objectives, and interventions based on the diagnostic criteria
Match DSM-V diagnostic codes with the corresponding ICD-10 code for easier billing

BestNotes EHR includes a list of diagnostic criteria to choose from. Once those criteria are selected and a diagnosis is picked, then BestNotes EHR software will auto-generate a list of goals, objective and interventions.  Clinicians also have the option to enter custom goals/objectives/interventions and other notes in the patient’s own words.

Streamline diagnosis, treatment, and billing today
Ready to improve patient outcomes and make your practice more efficient? BestNotes EHR is designed specifically for addiction treatment and other behavioral health providers. Contact us today to learn more and see a free demo!

date:  Jan 24, 2019
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The Importance of SOAP notes in an EHR

The SOAP (subjective, objective, assessment, and plan) note is one of the most commonly used forms of documentation in the healthcare industry today. Changing needs and increasing complexity in medical care have prompted questions about SOAP’s ongoing relevance.

With the appropriate EHR integration, SOAP remains useful for current healthcare needs.

History and Origins of the SOAP Note

In the early 20th century, there was no standard for health documentation. Dr. Lawrence Weed sought to create a more disciplined method for recording patient data.

Weed first developed problem-oriented medical records (POMR) in the 1950s. His revolutionary way of recording and monitoring patient information helped providers and facilities communicate more efficiently and keep more organized patient data. Weed’s POMR system evolved into the modern SOAP note.

How to Use SOAP Notes
The acronym SOAP involves the steps that providers should follow for entering patient data, starting from their first encounter with the patient.
1. Subjective: The Subjective step is how the patient describes their condition and reason for seeking care. This may include struggles with substance abuse or feelings of depression. The clinician should note all symptoms mentioned, as well as medical history, family health history, and changes in functioning.

2. Objective: This step includes specific measurements, test results, and exam findings. It may include current medications and other treatments. The clinician should include any changes from previous tests, if applicable.

3. Assessment: This section combines the previous two to establish a diagnosis. It may include a differential diagnosis if the patient’s condition changes or there is no specific diagnosis.
4. Plan: This section includes the clinician’s plan for treatment. This may include referrals or medication-assisted treatment (MAT). The plan should also include specific goals and scheduled follow-ups.

SOAP information helps improve quality of care and justifies a clinician’s charges in a third-party payer audit.

Current Concerns About SOAP Notes

Acronym order
Some clinicians have suggested changing SOAP to APSO, speeding up ongoing care and reducing the time needed to find the assessment and plan. Others have argued, however, that the APSO order could make a patient’s input appear less important. It may also make a clinician less inclined to conduct more thorough examinations.

Recording changes

Another concern about the use of the SOAP note is that it does not explicitly state where to record changes over time. Behavioral health and addiction treatment often involve complex conditions treated over the course of months or years. With the right EHR, however, SOAP notes can easily incorporate changes to a patient’s condition, treatment, and goals.

Including SOAP Notes in EHR

Including SOAP templates in a behavioral health EHR has numerous benefits. For example, BestNotes EHR solution provides:

Greater efficiency by eliminating double data entry
Autopopulating data from the EHR’s treatment plan section, such as diagnosis, goals, and interventions
Ability to review historical SOAP notes
Incorporate data points that make up the Golden Thread
Incorporate data from Outcome Measures

An EHR that supports SOAP

As an addiction treatment and behavioral health provider, your clients have complex needs. Your best EHR option is tailored to those unique needs.

BestNotes EHR offers progress notes, medication management, and a host of other features that improve your care while reducing costs. Contact us today to find out more, and try us out for free!

date:  Jan 21, 2019
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What Should You Know About Population Health Management?

Healthcare leaders frequently use the term “population health management,” despite persistent confusion about what it means and how it is applied.

Here we offer the basics of population health management and what it means for your behavioral health practice.

What is population health management?

Despite its widespread use, many experts disagree on the precise definition of “population health.” Generally speaking, population health means exactly what it sounds like: the health needs and concerns within a specific population of people.

In the American Journal of Public Health in 2003, Dr. David Kindig and Dr. Greg Stoddart suggested that population health be defined as, “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

For population health management, then, providers and payers can incorporate patient data with health IT solutions. This will help them track health trends and determine the best strategies for patients within that population. This, in turn, can also improve both clinical and financial outcomes for providers.

Why is population health management important?

As payers and other healthcare decision-makers increasingly focus on value-based care, and thus patient outcomes, population health management becomes a greater concern. Regardless of how experts specifically define the term, the main idea of population health is to focus on outcomes.

Based on the 11th Population Health and Care Coordination Colloquium in Philadelphia, the journal Population Health Management in 2011 listed three main goals of population health management as:

Maintaining patient health
Reducing patient health risks
Providing or coordinating appropriate patient care

The first two goals focus on prevention, an important factor in value-based care. The third goal involves care management. For behavioral health and addiction treatment providers, this usually includes improvements to patient self-management and medication management, as well as reductions to the cost of care.

What do behavioral health providers need for population health management?

A successful population health management program usually calls for a software solution that lets behavioral health practices collect and analyze data to establish a full picture of each patient. Ideally, providers then use this data to track and improve clinical outcomes and lower costs.
Behavioral health population health management should use both clinical and business solutions to make the practice more efficient as it improves patient care. Clinicians and administrators both should be able to obtain real-time insights to identify care gaps within the patient population. This helps them maintain a successful population health management program that leads to better outcomes and cost savings.

The right EHR can help your population health management.

For behavioral health and addiction treatment providers, patient populations tend to have complex needs with concurrent conditions. Behavioral-health patient populations often struggle with chronic pain and other disease, substance abuse, and mental-health disorders like depression. This creates additional challenges for providers focused on population health management.

To be successful, your population health management program should include an electronic health record (EHR) solution tailored for your practice’s specific needs. BestNotes EHR is designed specifically for behavioral health and addiction providers, with important features such as medication management, progress notes, lab ordering and tracking, and treatment plan reviews.

Contact BestNotes today to learn more about how we can help your population health management plan succeed.

date:  Jan 09, 2019
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