While the advent of the Electronic Health Record prompted hope and excitement for the possibility of data collection, seamless communication and sharing of information, and standardizing workflows, the actual result has been much frustration from providers and health systems due to the often cumbersome process of documenting and lack of true data reporting and collection. Behavioral health providers (BHPs) working in integrated care systems (e.g., Primary Care Behavioral Health [PCBH]) are not immune to this reality. Specifically, the challenges of concordant charting in a template that not only meets billing and coding requirements, collecting and reporting outcome and fidelity data, as well as is useable and functional documentation for other team members, are prevalent throughout the PCBH world. It can easily be assumed that one of the contributing factors to a lack of fidelity metrics being reported for PCBH within research projects is the lack of ability of health systems to pull data easily to show fidelity. Lastly, there also appears to be a dearth of guidance for PCBH programs in regards to EHR template development, further compounding an often frustrating reality for BHPs and administrators. This presentation will detail the development of a PCBH template at Community Health of Central Washington. Specifically, presenters will describe the iterations that have occurred to arrive at an EHR template that not only allows BHPs to concordant chart and meeting billing/coding requirements, but also produce useable information to the primary care team and fidelity data metrics. The presentation will also detail how a contextual influence has shaped the documentation to prompt BHPs and other medical providers to be intentional and compassionate through their documentation. Lastly, the presentation will provide an overview on how the documentation has evolved to easily adapt to telehealth billing requirements. Target audience members would be any BHPs working in a PCBH clinical setting, as well as administrators wanting to learn how to build templates from the ground up to meet billing/coding demands, as well as is able to report data and outcomes while not being cumbersome for providers to complete. Further, individuals who are wanting to learn how to make their documentation meaningful, contextual, and compassionate based would benefit from this presentation. This presentation helps address social inequalities through sharing information on how to make documentation compassionate/contextually focused, ensuring individuals served in the community have their context shared with the entire team. Further, developing an EHR template that produces minable data allows health inequities to be identified and actively addressed.
- Describe the steps taken to develop a PCBH EHR template that allows for coordinate charting and data reporting
- Describe how to subtly and directly make documentation contextual and compassionately influenced
- List steps their own organization can take to make their documentation more meaningful, minable, and workable