Electronic Medical Records in Therapy

We all know that electronic medical records are the wave of the future. The very near future. In fact, the wave is washing over me as I write this! The outpatient clinic where I do some fee-for-service transitioned this week from paper progress notes to computerized ones.

The change was accompanied by the usual technological glitches (I didn't have access to the drives when I got there, which was a definite issue!), and special trainings for those unfamiliar with the new format. Some of my colleagues have been resistant to the whole idea, but in general, I'm like the idea of going electronic. For one thing, all that writing takes a toll on my hand! I'm especially looking forward to being able to cut and paste things that are the same each time, but I've had to write out again and again anyway. It's also more convenient to reference past notes, assessments, and treatment plans, and makes it much easier to find out what other providers (e.g., prescribers) are doing with a client (not to mention being able to read what others have written!).

That said, there are also some drawbacks. For one thing, most clients are fairly comfortable with the idea of therapists writing during a session. Typing is another thing altogether. We're slowly getting used to medical doctors using a computer during consultations, but many people still feel like the computer distances patient from provider, or even complain that doctors don't seem to be listening (because they're looking at a screen). Since such a crucial part of therapy is feeling heard, anything that interferes with feeling heard is a problem.

Even if we position the computer strategically and touch-type so that we can maintain eye contact while making notes, we still have to think about the sound typing makes, and what effect that might have on the client. Hand-writing can be pretty unobtrusive - someone who is engaged in affective processing is probably not paying much attention to whether or what I'm writing. However, if I'm typing, it's clear when I am - and am not - writing. My prediction is that more clients would wind up wondering what I was writing as they began to notice the timing of writing - and to engage in projection and possibly transference about it.

From these reflections, it seems clear that typing notes (at least during sessions) would result in some changes in the feel of the session. The obvious solution, of course, is to NOT type notes during sessions, but do it after. That sounds like a great plan - but it assumes the luxury of 50 minute hours, with that ten minutes at the end for mundane things like paperwork. I don't know about you, but I don't live in a world of 50 minute hours. I live in the world of 45 minute back-to-back sessions before I have to run out the door to make it to my other job on time. Everyone I know who isn't in private practice has to think about productivity, and would have to do any paperwork that doesn't get done during the session on their own time.

So what's the solution? I don't really know. Better pay for lower productivity? We can only dream. Clients resigning themselves to typing during their sessions? I fear that's more likely. What do you think about how electronic medical records will or should be integrated into mental health treatment?

Things I Didn't Learn in School: The Numbers Game

An important skill to have if you want to do therapy for a living is getting clients to show up. As I discussed in a previous post, most salaried positions require a minimum number of "billable hours" per week (usually around 65% of the total hours worked), and both fee-for-service jobs and private practice only pay for billable hours. For all of us, there is a definite incentive to get clients in the door!

How hard that is depends in part on the population. With privately-insured populations, you or your agency may bill the client for no-shows or late cancellations (i.e., less than 24 hours notice). That puts some of the financial risk and incentive on the client - sharing the financial burden of no-shows. Of course, it's important to check the provider contract to make sure there isn't a clause barring this practice, and remember to bill the client rather than the insurance company (which won't pay for a service that wasn't provided!)

However, Medicaid does not allow its clients to be billed for no-shows. And since policies have to be applied uniformly to avoid discrimination, that means practices who treat anyone with Medicaid insurance can't bill any of their clients for no-shows. Except for private practices and very affluent communities, the majority of clinics fall into this category. Furthermore, clients dealing with poverty may face difficulty arranging reliable transportation, childcare, and phone service - all of which can interfere with attendance. 

The end result, at least where I work, is an average show-rate around 70%. If the productivity requirement is 65%, that means you have to have someone scheduled every hour just to meet the minimum! There go those bonuses, or that pay differential for fee-for-service staff, right? Not necessarily!

First, there are things you can do to get your show-rate up. Start by communicating to clients that you're reserving a time just for them, so it's important for them to be there, or cancel so that someone else can have the time. Reminders help - appointment cards, phone calls, postcards. So does a prompt follow-up by phone (or failing that, letter) to find out what happened and reschedule when someone no-shows. 

Then, you can hedge your bets by scheduling more people. Since a "billable hour" is really 45-50 minutes, you can schedule using 45-minute increments. That adds up to 10 clients in an 8 hour shift, with 30 minutes for lunch.

Those who are more daring can consider overlapping sessions - a form of double-booking. You would schedule the second session for around 15 minutes sooner than the first session would end, with subsequent sessions starting the full session length after than second session. So, for example, using 45 minute sessions: 9:00, 9:30, 10:15, 11:00.... Or using 60 minute sessions: 9:00, 9:45, 10:45, 11:45. Using this system, clients wait no more than 15 minutes (and only if everyone before them shows up, so it's best to schedule frequent no-showers early in the day), but you lose no more than 30 of 45, or 45 of 60 minutes.

It's important to think about your goals - both for productivity/income AND keeping your job manageable. It's possible to err on either side - too little productivity makes it hard to pay the bills, but too much can quickly become overwhelming, and make you less effective as a therapist!

Why You Should Consider Fee-for-Service

More and more, these days, mental health clinics are choosing to pay their employees on a fee-for-service rather than salary basis. The main difference is that salaried employees are paid by the clock hour, while fee-for-service employees are paid by the billable hour. Fee-for-service staff also may not receive benefits, though more companies are beginning to offer benefits to fee-for-service staff who meet minimum weekly averages.

Employers prefer the fee-for-service system for the same reason that employees prefer to be salaried - fee-for-service staff only get paid when the client shows up! 

However, there are actually some reasons to consider working fee-for-service, especially if benefits are included (or available through a significant other). 

1. Even salaried jobs have productivity requirements! If you're salaried, there is usually a minimum number of billable hours that you are expected to generate weekly. At both of my jobs, the requirement for salaried staff is 65% - that's 26 billable hours for a 40 hour position. Some agencies offer bonuses for exceeding the minimum on a monthly or quarterly basis - but take hours out of the bonus "bank" whenever the minimum is not reached. 
2. The hourly rate is higher for fee-for-service work. Since they're not paying you for non-billable hours, agencies can afford to offer more for billable hours. If you're motivated, and know how to keep your numbers up (to be discussed in a later post), that means you can end up making MORE money working fee-for-service than on a salary.
3. Fee-for-service jobs offer more flexibility if you want to work less than 40 hours a week (though many also have a weekly minimum - at my fee-for-service job, there's a minimum of 8 hours per week).

Of course, there are some caveats to consider before accepting a fee-for-service position:

1. Does the agency have enough clients to keep your schedule full? Be sure to ask about the size of the population, the turn-over, and rate of new clients being referred. If possible, try to speak with a current fee-for-service employee of the agency to find out whether they have difficulty booking enough clients. 
2. Do you budget money well? Keep in mind that most fee-for-service employees are not paid for vacations (though some are). You have to save some money through the year to cover the time you want off, and calculate your annual income based on the number of weeks per year you plan to work (e.g., 49 weeks if you want 3 weeks vacation). 
3. What is the average show rate, and how does it vary over a typical year? You have to plan for a certain percentage of cancellations and no-shows, which may spike around holidays, pay-days, and inclement weather.

In the current economic climate, job-seekers need to consider all possibilities, so I would encourage you to think about whether fee-for-service might be an option. It's not for everyone, but depending on your personality and finances, you may find it a better fit than a salaried position!