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Terry McLeod of ehrSIO ProjectsehrSIO Projects
A blog about the technical and software sides of mental health and addictions

Ignored by Tech

Terry McLeod Updated: Aug 19th 2013

Not really.

3D figure on laptopProfessionals reach out to me occasionally looking for an Electronic Medical Record (EMR) that works for a solo practitioner or somebody working in a small practice. More often than not, they are frustrated because they can't locate exactly what they want or are not necessarily tech savvy enough to configure and learn the software without aid of professional help. Moreover, they can't justify the expense involved in paying tech people to help them with this tech problem. For these folks, I want to say it's not a hopeless situation. There are some nice products out there that can help bring professionals into the 1990s, uh, I mean 2013, like TheraScribe

Just for the record, I define the EMR as a record that's limited to the practice and an Electronic Health Record (EHR) as a record capable of electronically sharing confidential consumer treatment information in a secure manner.

Most of the Electronic Health Record software (EHR) in the market caters to larger customers, organizations that employ a number of professionals sized from a Community Mental Health to a state psychiatric hospital system. A far cry from a solo practitioner, and not the market ThereScribe targets. The foundation of TheraScribe is treatment plan and assessment content. TheraScribe uses treatment plan content from Wiley Publishing, content also offered by a number of the manufacturers of larger systems. Checking into their website revealed a great education source in itself. If a professional wants to learn how the EMR ties to education, best practices, HIPAA and HITECH compliace, he could do worse than spending a couple hours with the TheraScribe website.

They even have audio-visual aids on the website. I reviewed their "get started" video recorded by TheraScribe creator Arthur Jongsma, PhD. The video gives a brief introduction to the electronic version of Treatment/Care Plans, Progress Notes, consumer homework and a bunch more. Jongsma says the software is quick & easy to learn, which you'd expect in a sales video, and on the surface it seems simple to me, however if you're making a decision on an EMR, I'd suggest you look deeply into the product and try to connect with another professional or three who are actually using it successfully. References for products sometimes turn into mentors and we all need mentors.

The brief presentation started with the input of consumer standard demographics like name and address, and included gathering insurance information including authorizations (a novel approach to start at the beginning). If a professional has avoided working with insurance companies because the work involved can be more trouble than it's worth, software like this combined with third party billers can increase revenue…and who doesn't like the idea of a few more sheckles arriving in the mail?

I like that this product is enabled to attach electronic documents to the patient record, like scans, photos and PDFs. Sometimes outside information needs to come in because it's valuable in treatment, and sometimes it's valuable in billing, and this is a great organizational tool. The next trick is to make the document easily accessible, and you may want to ask a salesperson to show you how that happens in the software; sometimes it hard to locate the documents you attach to a record.

A huge advantage TheraScribe has is a design tool; it doesn't appear too robust and may be limited in what it can do to modify the system to suit special needs, however you can create some custom fields in your EMR, and not all products will let you do that. Sometimes state and local licensing requirements insist certain information be tracked, and being able to add in a data field could be just the ticket to stay on the right side of the rules and regulations.

Sharing of Patient Health Information (PHI) is tracked in the software's HIPAA module and enables recording of signed release forms and other documents required to keep consumer information confidential and prove that you're following the rules. EHR software serving organizations need to be Meaningful Use certified, and this sort of thing is a pre-requisite, however for a solo professional this consideration seldom comes into play so TheraScribe isn't certified. Still, even without certification, the rules need to be followed and sharing of consumer data needs special attention, and the software attempts to address the issue.

The assessment collects narrative about family, development, substance abuse, socio-economic factors and medical history. The thing that jumped out at me was the lack of check boxes to provide measurable metrics about the makeup of your practice over its lifetime. Other standard information like strengths and weaknesses have multiple select checkboxes, which the user can add to. A professional may want to check into this sort of functionality further if scientific method to improve a practice seems important.

If a professional uses a licensed assessment instrument, use of the tool and the scores can be noted in the consumer's record, however you don't see instruments in the system, simply because that would be infringement of another company's intellectual property.

The mental status exam follows the same pattern as recording strengths and weaknesses with lots of check boxes, indicating risk assessment, thought form and content, as well as a narrative for the professional's summary.

The Recovery section of the software is based on ASAM criteria, delivering a score to justify a level of care selected for a consumer; once again, narrative enables descriptions of outcome. If you like this sort of thing, it could come in handy.

One great fact about TheraScribe is that a solo professional can get some of the EMR functionality that they thought was reserved for peers working in large organizations. Once a professional gets used to using an EMR, they seldom want to do without it. The fact is, good documentation can help professionals deliver a high quality of care, and certainly extend billing into new payers (insurance).

If you're a professional in the market for an EMR that would work in a solo setting, TheraScribe is certainly worth a look.


Terry McLeod

Electronic Health Records (EHRs) are a required part of our society, and improving business workflows with the EHR is imperative for the survival of your local mental health and addictions treatment clinics. Terry McLeod provides the bridge between the mental health and addictions professional and the technical world, as well as the glue to keep it working. Contact McLeod at and get more information from his website and blog,

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