: Integrating the Electronic Health Record into Behavioral Health Encounters: Strategies, Barriers, and Implications for Practice

Background and Purpose: Electronic health records (EHRs) are increasingly prevalent in both health and mental health care settings. Despite the rapid adoption of these systems, little is known about how to optimally integrate such technology into clinical encounters. Research conducted within the medical community suggest that some providers struggle to integrate EHRs into existing clinical workflows and maintain rapport with patients when computers are introduced into exam rooms. Comparable studies exploring the experience of behavioral health professionals using EHRs have yet to emerge in the literature. Such research will be critical in developing best practices related to EHR use within the unique context of behavioral health care. In order to address this gap in the literature, this qualitative study addresses the following research questions: 1) how do behavioral health professionals use EHRs during clinical encounters?; (2) what strategies do clinicians use to effectively integrate these systems into care?; and finally (3) what barriers may prevent clinicians from using EHR’s during clinical encounters?

Methods: This qualitative study sampled behavioral health staff from a large community health center network that has been using EHR systems for over a decade. Semi-structured interviews were conducted with 37 behavioral health providers, including case managers (n=3) licensed therapists (n=28), psychiatrists (n=4) and administrators (n=2). Interview questions were organized around several sensitizing concepts derived from the literature, including documentation practices, patient satisfaction, engagement, and efficiency. Open coding was used to organize transcribed interviews by sensitizing concepts. Iterative, thematic analysis was employed in order to distill common elements in to more meaningful themes. Negative cases were then compared using a contrast table in order to identify important sources of variation.

 

Results: Providers unanimously preferred electronic systems to traditional, paper charting, and found that their clients were generally receptive to EHR use during visits. Thematic analysis identified several strategies that allowed providers to use the EHRs as a tool to enhance the patient-centeredness of clinical encounters, which were classified across three domains. Environmental strategies encompass ways in which providers manipulated the physical environment to facilitate engaging uses of the EHR systems using treatment. Relational strategies described ways in which providers altered communication patterns to integrate the computer into the clinical encounter. Lastly, system related strategies include ways in which specific features of the EHR were used to facilitate meaningful dialogue around wellness and recovery. These strategies were typically employed in tandem, and were collectively perceived to enhance patient-centered communication during visits. Providers also described a number of factors that could stymie the deployment of these techniques, including time constraints, computer literacy, varying clinical orientations and functional limitations of these systems.

Conclusions: These findings suggest that EHR systems can be used strategically to advance patient-centered behavioral health care, but not without deliberately restructuring the way treatment is provided. EHR systems appeared to have a conspicuous presence during treatment, and because of this, barriers preventing providers from effectively deploying strategies for meaningful EHR use may actually detract from patient-centered communications. Implications for policy and practice will be discussed.