The Impact of Collaborative Documentation on the Therapeutic Alliance in Behavioral Health Treatment

Background and Purpose: The use of electronic health records (EHRs) is becoming normative in behavioral health treatment. Despite this, little is known about how to optimally integrate such technology into clinical encounters, and providers express concern about potential damage to the client-provider relationship, or therapeutic alliance (TA). Collaborative documentation (CD), the process of completing progress notes jointly with clients, has been promoted as a model of in-session computer use that can enhance TA but has been controversial among behavioral health providers. Advancement of CD has been hindered by the lack of empirical studies examining its effectiveness. This quantitative study examines how behavioral health providers use EHRs within a therapeutic context and  the impact CD has on the client-provider TA.    

Methods: This study drew from a sample of 53 therapy sessions where EHRs were used. A total of 13 behavioral health providers and 53 clients participated in the study. Data sources included a video recording of each session, and post-visit surveys completed by both clients and providers. Video data was coded for computing frequency, and the use of CD with clients. Surveys measured client and provider ratings of the TA and CD. Univariate statistics describe the extent of computer use during sessions. Paired sample t-tests explored differences in client and provider perceptions of TA and CD. Finally, the association between the amount of computer use, CD and TA was tested using OLS regression, adjusting for nesting with a random effect at the provider level. The first model examined the direct effects of CD on TA  A second model explored the moderating effects of CD on the relationship between total computing and TA. 

Results: Results indicate that providers engaged in an average of 42(SD=38.5) separate instances of computer use. Paired sample t-tests were used to compare mean scores of provider and client perceptions of TA and CD. Clients reported significantly higher alliance scores (M=6.3, SD=.59) compared to providers (M=5.8, SD; .67; t=6.8, p<.001). Clients rated computer use as less disruptive (M=1.57, SD=1.2) than providers (M=2.3, SD=1.1; t=3.4, p<.001) and more transparent (M=4.2, SD=1.3) than providers (M=3.7, SD=1.0, t=2.7 p<.01). OLS regression explored the relationship between total computing, CD, and the therapeutic alliance. Among providers, total computing predicted decreases in alliance (B=-.18, p<.05). This relationship was not moderated by the use of CD. Conversely, among clients, CD had a direct, positive relationship with alliance (B=.43, p<.01).  

Conclusions and Implications: Findings suggest that computers are a salient component of behavioral health treatment, but clients and providers view the impact of computers on the quality of care differently. While providers felt pessimistically about the impact of EHRs on alliance, clients did not share this experience, particularly when CD was deployed. To this end, results indicate that requisite skills surrounding collaborative use of technology are critical to harnessing the benefits of this technology. This underscores the need to continue developing and disseminating effective strategies for EHR use.