Love/Hate Relationship with Electronic Medical Records

When I first posted this, I realized it was too serious for me.  So I decided to add a ponderous Bowie.

When I first posted this, I realized it was too serious for me. So I decided to open it up with a ponderous Bowie.

I recently started my Pre-Doctoral Internship.  Much like my previous training site, I’m in the Community Mental Health (CMH) world.  Unlike my previous site, I have Electronic Medical Records! (EMR)

I am actually excited about this fact because paper record keeping was absolute shite at my old training site.  Things got lost, accidentally shredded, or re-done a thousand times because it had a minor error.  Everything was constantly a mess.  Intake appointments were up to 3 hours long and required over 50 pages of documentation, most of which had to be hand-written.   Even after that 3 hour intake appointment, there was at least 2-3 more hours of cleaning up and re-checking paperwork before it could be sent off and *hopefully* approved for billing.  You can imagine how exhausting this was for both the staff and the clients.  And of course none of that paperwork time was billable.  So a 40 hour work week for staff (therapists, respite workers, case managers) would usually consist of maybe 15-18 billable client hours (I know this because I’m obsessed with counting and quantifying things and looking at charts of things).  It took up to 3 months to get feedback on this crazy paperwork.  If things did not get into the record immediately, there were often massive miscommunications between members of the treatment team.  A psychiatrist would change a client’s medication and the therapist would not know about it for weeks.  A client would skip therapy or skills or job training and the psychiatrist would know nothing about it.  Crisis alerts for clients were often mis-filed or not provided to the client until days later.  If paperwork expired and we weren’t on our toes about exact dates and made sure to schedules ourselves a few extra hours to update paperwork on the plucked-out-of-thin-air medicaid-demanded dates (all of which were different between treatment plans, evaluations, updated consent forms, etc), we lost billing, meaning we lost the only funding that keeps the doors open to the only mental health resource available to most of the people we served.


Overall, it interrupted treatment.  It interfered with the ability to provide treatment.  So much time was spent completing paperwork and ensure that medicaid would pay for the work that was done, that client need often had to be put aside for the time being while we made sure we were compliant with governmental demands.  And of course when client charts or information got lost, it was always the one with pre-existing paranoia ideation.  Serendipity, bitches.

And this was not because of poor management of the site.  They honestly did the best they could trying to stay on top of everything.  But it honestly felt like every month or so medicaid was demanding more documentation.  We were overloaded, understaffed, and underfunded for what was placed on the agency.  Because of these outrageous demands, we were forced to keep relatively small client loads, which lead to an overflowing waitlist.  This means that both adults and children with mental illnesses, developmental disabilities, trauma, and other problems demanding mental health care were forced to wait up to 6 months for services.  This includes people released from the hospital following a suicide attempt.  People with active psychosis.  And those with a history of violence and aggression.  These are all people that are in desperate need of care, low-to-no income, and are struggling to meet the demands of their daily life.  However, they are all also people who had the potential to succeed and contribute with the right help and resources.  Many of them are children and adolescents whose potential you could feel if you could just get them and their families in the door and on your caseload.  This is the story of many CMH’s out there.


Oh, and did I mention that, because CMH is so underfunded that nearly every staff member has to travel between multiple sites and rarely has a consistent schedule?  So communication between treatment providers is difficult to say the least.  A CMH psychiatrist (that’s the one that prescribes meds but does not provide skills training or psychotherapy) may work at 4 different locations throughout the week and see upwards of 50 clients per day (10-15 minute appointments).

So, my at my new site we have EMR.  Which is so much more convenient.  Everything is right in front of us on a single website, from Treatment Consents to Intake Assesssments to communication forms between treatment providers.  Because everything is in one location, you get alerts for when things are coming due.  If a client misses an appointment, the entire treatment team can be alerted immediately.  Rather than 3 hours, intakes are about 1 hour.  I have constant access to everything in my clients’ records, no matter what office I’m at, or even if I’m doing a home or school visit.  It is infinitely easier to get my work done and move on to focus on my clients’ needs.  I can instant message my supervisor or other member of a client’s treatment team the moment there is an issue or just to alert them to progress made.  A client can review their records easily with me and helps fill out progress notes, which feels more open and honest, and opens to door to discussions about how they view the therapy and their progress.  If a client’s medications get changed or they are assessed by the crisis team, I know immediately that a change was made to their record.  It’s golden.

Unfortunately, the Orwellian in me cannot fully embrace this.  Being CMH, it is a government agency, funded primarily by medicate and overseen by the Health Department and everything that goes with that.  I’ve been on a bit of a paranoid kick myself lately–how could you not be in America right now?  I’ve been following the NSA/Manning/Snowden stories and I’ve been appalled by what I’ve been reading.  How much information is viewed and stored about people.  How many emails and searches are read.  There is no guarantee that any of my emails are secure and everyone that comes in the door is made aware that their information is reported to various agencies.  Most clients, though, are in too great of a need to worry about confidentiality and governmental information gathering.  How do I explain confidentiality to a client when I know that nothing is really confidential because it is being reported to various agencies.  There is nothing so great about out EMR that makes it hack-proof.  Do I think that the NSA really cares that much about a 15 year old girl’s depression?  No.  But the fact is, nothing about EMR really is secure.  But with the massive integrating of all of this information, is it really that outlandish to believe that this information could show up somewhere else in the future where it might hurt the person?  What if the 15 year old girl later decides to apply for positions in the Military or CIA and they have access to these mental health records?  Could that affect them?  I really don’t know.  I am being told that this information is secure and confidential, but to be honest even my supervisor does not sound that convinced of it.  What if I do have to write a report on a client having paranoid ideation regarding the government?  What if I have to email my supervisor regarding a client’s flight of ideas about militias and terrorism?  How secure and safe are these mental health records?  (Our voice mails also go directly to email)


So, I am still torn over the EMR thing.  It is amazingly efficient and leads to better record keeping and communication within the treatment team and therefore more effective and ethical treatment.  However, I have significant concerns over confidentiality and how long this information is kept and for what purposes it can be used.  My fears being heavily influenced by the happenings within my country.



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