A behavioural health EHR is the electronic health record used by services for mental health, addiction treatment and long-term care at home. Behavioural health is the American term for mental health and addiction care together. These records are sold mainly to care providers in the United States, and much of the software is built in Bengaluru.
Why do these services need a record of their own? A clinic visit leaves one note from one doctor. Behavioural health care is different. A patient may be seen many times a week, for months, by several people: a psychiatrist, a counsellor, a nurse, a social worker and a home carer. Each of them writes a note after each session. The record must also hold a treatment plan, a written plan with goals that the team reviews every few weeks. Every session must be linked to a goal in the plan, because the payer checks this before it pays.
Take, for example, a 12-week outpatient addiction programme in Kentucky. A 34-year-old woman joins it to stop using opioids, a class of strong painkillers. On day 1, the counsellor records an assessment and a treatment plan with three goals. One goal is to attend three group sessions a week. She also sees a doctor, who prescribes a medicine that reduces her cravings, and a nurse, who checks on her every week. By week 12, her record holds about 60 notes from five people, each linked to a goal.
Her record has extra protection. Under United States federal rules, records of addiction treatment may be shared only with the patient's written consent, even with her other doctors. So the record keeps track of whom she has allowed to see what.
Much of this care is paid for by Medicaid, the American government health plan for people with low incomes. Each session is billed separately, through revenue cycle management software. Some services, such as extra weeks in the programme, need the payer's approval first, called prior authorisation. The payer's care management team may also follow her progress.
Writing 60 notes takes the carers many hours. So these records now include an AI medical scribe. With the patient's consent, it listens to a session and drafts the note for the counsellor to check. It also links the note to the right goal in the plan.
In home care, the record works on a phone. The carer opens the visit in an app at the patient's door, records the tasks done, and closes the visit on leaving. Medicaid requires such an electronic record of each home-care visit, including when and where it took place.