Modifying OpenEMR for Mental Health Clinics

OpenEMR Development
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I know it’s been a few years since the last post (2013) about the possibility of using OpenEMR for Mental Health Clinics, but has their been any progress?

As a mental health professional in private practice, and trying to create my own group practice, I have found configuring OpenEMR confusing and, well - it’s incredibly daunting for those of us who have relied on other EHR/EMR’s for billing and clinical notes - and I was a computer IT person well before entering the mental health field. It took me literally hours to just figure out how to setup clinic information - i’ve yet to figure out how to enter billing information and price structures (fee sheets are grey’d out, I am obviously missing something somewhere that has to be done before I can create my pricing for services? As in CPT codes…).

I’ve tried looking through user manuals and other forums, but there seems to be limited information for those of us who are completely new (and don’t make a lot of money to hire people) to setting up a comprehensive EMR/EHR - especially for a mental health clinic.

Any advice?

Thank you so much in advance for any help anyone can offer.

Kenn

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Yes, and no. There are a few developers out there that have created things that would help Mental Health practices. But none of it has been submitted back to the code base including my own stuff.

I am trying with a first step towards automating the billing.

I need to finish this soap note that attaches billing to the fee sheet without you having to fill out the fee sheet. I will try to get this done before the next patch comes out and I will alert you to its completion.

My question to you is can you share with me your ideal workflow so that the billing is done automatically in the background for you. Because with some of the items that Ken has done. This is closer than ever to possible.

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I found these pages that seem to address entering fees, from V3
https://www.open-emr.org/wiki/index.php/Preparing_for_Billing_and_using_the_Fee_Sheet
https://www.open-emr.org/wiki/index.php/HOWTO:_Create_Multiple_Code_Fee_Sheet_List_Categories

Looks like some sort of ICD upload is needed

You probably need to be logged in as admin, but you know this.

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Hi @kjnelan -
I’ve been doing OpenEMR customer support for several years and have helped several Mental Health clinics adapt OpenEMR for their use. OpenEMR does have the capability to support MH practices but it does take a bit of doing since 1) most MH practices seem to have have their own unique workflows for seeing their patients, 2) those workflows have few or no medical activities in them which OpenEMR was designed to support and 3) often billing arrangements are quite different from standard medical insurance.

Like you, plenty of MH providers have posted here in the OpenEMR forum looking for the same help as you are. Consequently, doing a forum search for ‘mental health’ and ‘behavioral health’ will return a lot of discussion and information on adapting OpenEMR.

But here are some tips to get you further along your quest.

The OpenEMR wiki is a treasure trove of information, even if it can be difficult to find relevant information sometimes. I have some links below to look at on some topics, but otherwise the best way to use the wiki is to search (using the search function in the left margin) for pages about the topics of interest.

OpenEMR has the Layout Based Forms (LBFs) capability which allows the user to create their own clinical forms. That’s another good search term for the forum. But here’s the latest wiki docs on LBFs
https://www.open-emr.org/wiki/index.php/Sample_Layout_Based_Visit_Form

LBFs were originally ‘Layout Based Visit forms’ (‘LBV forms’). This is some older documentation but still useful.
https://www.open-emr.org/wiki/index.php/LBV_Forms

Since the CPT codeset is a paid subscription and no practice I’ve heard of would ever use all the codes it contains, practices usually opt to manually enter the small subset of codes they do actually use. The link that @VWfeature posted is the most useful info on fee sheet codes, which is how you would enter CPT codes.
Another good one for a related but different use case is: https://www.open-emr.org/wiki/index.php/OpenEMR_4.2.0_Fee_Sheet_Custom_Service_Categories

DSM-V diagnoses are also a paid subscription so must be entered as you would the CPT codes. Alternatively, they are a subset of the ICD-10 codes which are included in the default EMR so you could use the MH ICD codes for free.

I suspect that the greyed out fee sheet you saw is because you need to have a patient’s encounter form active before you can open the fee sheet that records the fees for the services rendered in that encounter.

OpenEMR is an extremely capable application but with capability comes complexity. And while nothing is completely free (except the advice here on the forum) if you can invest the time and effort to learn how to do everything yourself, your monetary investment using OpenEMR will be minimal.

Please feel free to post more questions here- that’s what the forum is for!
Best- Harley

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Hi Harley;

Thank you for your very detailed and comprehensive response, but I do feel I need to address something you mentioned - the workflow that has few or no medical activities and the billing arrangement different from medical insurance. If by medical activities you mean physical vitals, you are correct, however, we who are licensed professionals do have other assessments we do that are equally as important as physical vitals - our mental health vitals may be different, but the modification would be a simple likert scale on MH wellness. Other than that, we still have to chart, note, and provide proof of medical necessity for our services. In terms of billing - I’m not sure what you mean by standard medical insurance. As a medical provider (Licensed Professional Counselor), I take “standard medical insurance” and bill according to the standard ICD-10 and CPT codes to the same medical insurances as physical medical providers (I’ve never heard of someone just using DSM-V - we HAVE to use ICD-10 and CPT to bill; we use the DSM to justify symptomology, not for billing). My diagnoses are valid medical diagnosis and must be backed by sound symptomology. I even use a medical billing service for my cms1500’s, ERA’s, EOB’s, and EFT’s. I take copays, cash pays, and insurance - just like other medical professionals - as so most, if not all of my colleagues (except for those who are purely cash only practitioners). So… not sure what to do with that info about insurance and the DSM-V…

In terms of the greyed out fee sheet - I’ve not found where to even enter my CPT codes and my insurance contracted fees.

With regard to nothing being completely free… I’ve paid thousands of dollars per year to EHR’s to do what I’m now trying to do with OpenEMR. Investing time is, at this point, a joy if I can get it to do what I need it to do…

Thank you for the links to information - I’ll look them over and apply as able.

Kenn

I’ve poured through the knowledge base and wikis but can only find information for MH professionals from 2016 and later - nothing in recent years, and while I am fairly knowledgeable in programming, I don’t want to reinvent the already complex wheel.

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Thank you, Peter - great information - I’ll try to work on that portion this week.

Kenn

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Hi Sherwin;

Workflow. Okay, not sure what you mean by this so I’m just going on what a typical session would look like for any clinician.

1.) patient enters and a cursory assessment is done to see where they are at in that moment - this usually takes the form of assessing for depression, anxiety, or any other things associated with the client’s primary billing Dx. (our Dx’s rarely change unless the patient has been in therapy for a period of time and has worked through those issues).
2.) after the cursory assessment, processing begins (the bulk of the session - generally 50 minutes in length unless it is a 30 min session).
3.) a plan (homework) is made with the client
4.) after the client has left, all notes are completed and the client is billed for the appropriate session (individual at 50 min, fam session, group, etc… always in the form of CPT codes).

For some of the EHR’s I have used, billing will not take place unless the notes are completed, in others one could bill without notes as they are generally not sent with cms1500’s or electronic billing.

During note taking, we can use whatever forms we prefer. Most of us use SOAP, but there are also freehand forms and others that are much more structured. I personally use a very structured report/note system/form that I created specific for my own needs - but that is in another EHR.

I hope that’s what you were looking for, if not, just let me know and I’ll try to provide what I can! :smiley:

Thank you

Kenn

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@kjnelan
Thanks for taking the time to write the workflow down. It will help someone in the future. I hope the soap billing gets into the codebase. That could help adopters of the program do billing faster.

I was thinking of creating a different dashboard for behavioral health. If you don’t mind me picking your brain. If you could redesign the dashboard for your client. What would that dashboard look like? If you could upload that in a word document, that would be great.

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Hi Sherwin;

Changes to a dashboard is going to take some thought so this might take me a few days. I want to spend some time with a couple of fake patient accounts and a fake practitioner account, as well as spend time in the EHR I currently use.

I spent some time trying to create fee sheets, but the wikis seem terribly outdated as none of the menu items matched. I was able to find lists, but of course no fee sheet, so I’m assuming one has to be created from scratch. I’m going to spend more time on this and the dashboard experience this week.

I’m really hoping OpenEMR will work for our clinic…

Kenn

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Hi @kjnelan
To create a fee sheet is done from encounter or you need to have a patient encounter up to access from top menu.
All our billing is mostly encounter based.
You can create cpt4 codes at Administration->Coding->Codes and set pricing there. Also look into Superbill which some really like. You can set price levels as well to group pricing. We also have an inventory module if you’re dispensing drugs or products.

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Hi Jerry;

PERFECT!!! Exactly what I’ve been pulling out my limited amount of hair looking for!!! Brilliant! Thank you!

As far as I know, all MH is the same - encounter based. I guess I mixed up fee sheet with the place to define the fees for the CPT codes. In other EHR’s, the Fee Sheet is where we set the fee structure. I’ll be sure to make note of the change of language. :wink:

Kenn

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Glad it helped Ken,
Try to ask specific questions and it will make it easier to help. We have several very proactive vendors that donate back to the community by helping folks such as yourself. I think you’ve seen a couple thus far.

We also have a therapy group module you turn on in globals. Some in US use while others have told me it won’t suffice for US. In Globals under Appearance Enable Group Therapy

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@kjnelan and here’s the wiki documentation for that module:
https://www.open-emr.org/wiki/index.php/HOWTO_Setup_and_Use_OpenEMR_Groups_Module

Best- Harley

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Sorry for the late response - the last week or so has been hectic.

Okay - “Group Therapy”. Perhaps I’m splitting hairs here, but in the Mental Health world, “Group Therapy” is a different animal than what is being portrayed in OpenEMR. In Mental Health, “Group Therapy” is literally just that - where a group of people come together for therapy. Otherwise we use the term “Group Practice”, as do most medical offices I know.

But, for the record, I found that setting early in my wanderings through the settings, was already flummoxed by it, looked it up, and configured it per the Wikis. I recall it did take me a while to find the mentioned ACL’s (Access Control List) as that setting was not shown in that particular Wiki. I did all that and then discovered that this setting had nothing to do with “Group Therapy”, but was instead a setting for “Group Practices” and had to revert everything since I only have one location. I’m still trying to figure out how to setup for and bill for a group therapy session where I have 5 or more people come in for therapy. But that is not a priority - figuring out the billing is more important right now, as well as patient portals (already setup, I think), and being able to properly document the therapy session.

I’m still working on the Dashboard (@juggernautsei if by that you meant the patient dashboard?). From what I’ve seen of it, it’s pretty comprehensive except for getting to a place where I can enter notes for a given appointment seems fairly difficult. It took me a while to find it the first few times - it just doesn’t seem user friendly for MH. But right now I’m more focused on insurance and billing… :wink:

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@kjnelan So I think the interface is cumbersome, but you should be able to do Group Therapy using that module that @htuck referenced. When you create the group you will only assign yourself (or whoever is running the group) as the Main counselor, you don’t need multiple counselors assigned to a group (as you would w/ a Group Practice). Once you’ve created your group you can add participants to the group.

I just walked through an example just now to make sure it was working. I think we need to improve the user interface design on all of this, but it does let you add participants who would all attend a group session.

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These module was built before my time, and I would like to improve the way therapist notes are entered to be simpler similar to how TherapyNotes, or SimplePractice does it. Those are the two Mental Health EMRs I’m most familiar with. I know that @juggernautsei has done a lot in this space so he might have some UI enhancements that he could help you with that aren’t currently in the core OpenEMR codebase.

Once I’m finished with OpenEMR’s FHIR project (which is needed for MU3 certification), if you are still needing help I would be interested in talking with you as I do a lot of stuff in the mental health space.
I have a number of ideas and desires to improve OpenEMR for mental health clinicians.

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Thank you so much for the clarification - I must have gotten lost somewhere in the instructions or explanations for the group setup. I’ll give it another go with a fresh mind in a couple of days. Thank you all for your patience with me as I muddle through all of this - I’m doing this quite literally on my own in my practice - no one else has the computer savvy to help.

I have used TherapyNotes and Theranest in the past, and currently use SimplePractice but it just doesn’t give me the reports I need that Theranest had, which didn’t have the billing features that, honestly, none of them had except for myself when I was sending CMS-1500’s by mail manually, which I may go back to doing given the horrible experiences I’ve had with EOB’s and ERA’s. The three have had their benefits and their serious flaws (which is mostly around billing and reports).

I am also, frankly, leery about letting someone else have access to my medical files. I have always preferred open source and self-hosting whenever possible. We have our own server and I’d like to put it to good use!!!

In terms of notes - I’m a bit different than most MH people in that I recognize we are truly medical professionals making qualified medical diagnosis, though many have only earned masters degrees. While I am all for click and fill, if done right, I am more medically minded and prefer entering what is necessary to prove medical necessity for the counseling session. I have my own preferred format for entering notes and have always used a specific format for notation:

Session Focus:
Observations:
Progress:
Interventions:
Medication Changes:
Additional Notes:
Plan:

Since I copy and paste this from a template document that is always open, notes aren’t that big of a deal - again, for me. Finding where to enter the notes… now that’s an issue, but over the day I’ve gotten used to the layout and where to find the entry. It’s growing on me - quickly!!! :smiley:

Now, unfortunately, back to work - I’ve clients through the evening that start in about 45 minutes.

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I am now working with a mental health nursing home and there are two issues. First, I plan to use an inpatient module that keeps track of beds, rooms and patients. I published about it in another posting.
Second, I need a daily sheet with medication for each patient, for nurses. I do not want to enter each patient record, because it takes time, but just do a single operation for querying and printing. If nobody did it, I guess I will write it myself.

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Hi @kjnelan
I’m guilty of having written those group module instructions! Can you please tell me what isn’t clear? I’d love to update them to make them better.

  • Harley
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Hi, I am new to openemr. Need help with setup and customization for behavioral health facility. Please message me if you are interested.

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I was wondering if there is a way to create claims from the group therapy encounter for all participants? I appears that the fee sheet is grayed out for groups. Is there a separate workflow? thx…