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What Does a Substance Use Facility Need in an EHR?

PUBLISHED ON: 10.04.2018

When it comes to substance use treatment, it’s important to understand what does a substance use facility need in an EHR? An EHR is instrumental in fostering better care coordination and improving clinical care and in order to meet the demands of addiction rehabilitation facilities, an EHR must account for both the operational needs of the agency – and the unique functional needs of clients, such as IOP (intensive outpatient) and inpatient-specific options.

One of the main challenges for substance use treatment is the coordination of care, within the organization, across multiple services and providers. This means substance use agencies typically need EHR functionality such as ePrescribing, Decision Support, and Lab Integration.

They also often look for certified programs that qualify them to participate in federal incentive programs such as MACRA / MIPS.

PIMSY offers all of the above-mentioned substance-use EHR functionality, plus it also provides streamlined data entry, robust electronic billing, and customizable organization-wide reporting & accountability tools.

Specific functionality that you should look for in a Substance Use EHR:


e-Prescribing allows physicians, nurse practitioners, and psychiatrists to electronically send prescriptions to a pharmacy instead of having to fax or call it in. Connecting the point of care directly to the pharmacy improves communication and collaboration; decreases the risk of medical error or prescription fraud; minimizes the risk of drug-to-drug or drug-to-allergy interaction; and improves medication adherence.

When integrated with an EHR, you can manage medications, view patient history, and send prescriptions – all from one place! If you are a psychiatrist or a clinician who is responsible for prescribing medication, your organization may benefit greatly from e-prescribing integrated with your EHR.

PIMSY has been partnered with H2H Solutions for e-Prescribing since 2011, as part of our initial Meaningful Use Certification, and utilizes Digital Rx. This is a two-way electronic communication, which means that not only will the pharmacy receive the scripts electronically, but if the pharmacist has a question or issue, they can send that info back through Digital Rx – right into PIMSY for the clinician to receive.


Using PIMSY’s eMAR capabilities, you can track exactly which medications are administered to which client: by whom, where, and when. Not only does the eMAR feature give you total medication accountability, but it reduces administrative errors and decreases documentation time.

With built in inventory and tracking, eMar allows a facility to track the med bottles, auto-decrement the bottle counts according to what has been dosed, and allows for matching of manual bottle counts to the system counts. For organizations that work directly with a pharmacy, or have an onsite pharmacy, this tracking can be linked to the original package all the way down to the individual pills. Bar code scanning technology is integrated with this feature.

Bed Management

For agencies offering inpatient treatment, you need to be able to see the real-time status of all the clients in your facility – and create a daily bed attendance log & daily notes for everyone in the program, easily and efficiently.

With PIMSY’s color-coded bed management screen, you can quickly & easily schedule beds, maintain a waiting list, and determine when a space should become available. Click here for details.

Comprehensive Session Notes: Assessment, Progress, Group, and Team

Treatment for SUDs often requires integrated case management. This means that record-tracking; follow-up plans of care; and the development of performance indicators – in a shared clinical decision-making platform – are all essential to effective treatment.

Strong note management capabilities in an EHR help to: monitor a patient’s progress, avoid redundant treatment, and encourage adherence to the treatment plan. Robust notes – of various types – also ensure that all of the information & authorization management contained in a client’s chart are both integrated and easily accessible.

PIMSY offers customizable, comprehensive templates for all four note types: assessment, progress, group, and team. Our customers love that they can tailor the notes to their specifications; that treatment plan goals pull directly into the note; as do surveys, completed by the client on the patient portal.

Providers have the option of attaching documents directly to a note (art work, psychotherapy notations, etc). Baseline data provided at the time of service is quantified to provide measurable results in how the client is responding to their interventions and working to meet their goals. With PIMSY’s brand-new Treatment Plan Outcome Measures, each goal can be measured directly from the note, which is then correlated and graphed onto the treatment plan.

Clinical Decision Support

Decision Support is customizable to your specs and can be deployed across multiple areas of the system. When entering your data into PIMSY, decision support automatically pops up – alerting you to client care data.

HIPAA-Compliant Telehealth

To assist long distance client-clinician contact, PIMSY has partnered with Secure Video to offer integrated HIPAA-compliant telehealth services. This capability allows you to conduct a session right from your PIMSY calendar and sends automatic meeting invitations to your clients for seamless scheduling. Telehealth is especially invaluable as vulnerable populations continue to social distance and/or quarantine due to COVID-19.

Lab Integration


With lab integration, you can pull lab result files directly into your EHR software, flag any criteria you want to monitor (such as having all positive drug tests show up red in the results) and can pull global reports based off those results. With PIMSY, you can attach the results to the client chart without having to scan, type, or otherwise enter data.

UB-04 Billing

UB-04 billing is a type of billing an institutional provider can use for the reimbursement of medical and mental health claims. Billing for IOP and inpatient services is a very unique functionality that some EHRs do not consider when creating their billing rules and procedures but can be a valuable function in an EMR.

PIMSY can seamlessly process and easily accommodate the special needs of all UB-04 billing, allowing full control over the type of bill, attending provider and rev code specifics for all inpatient claims including residential facilities, IOP/PHP services and other institutional claims.

HIPAA – CFR 42 Part 2 – Secure Hosting

Personal Health Information (PHI) security, HIPAA compliance, and adherence to CFR 42 Part 2 is important for any agency, but is especially crucial for substance use facilities. In order to protect your data and ensure compliance, an EHR should have secure hosting that adheres to HIPAA protocols; encrypts communications and operation processes; blocks unauthorized traffic; and manages threats.

PIMSY hosts all data on Microsoft Azure, with Cloud services to provide solid data encryption and security. This means that your client and agency data is being backed up, multiple times daily, to one of the world’s most secure Cloud providers, at three of their different geo-locations. See details about how PIMSY helps you maintain compliance with both HIPAA – and CFR 42 Part 2.

MIPS – Meaningful Use – MACRA

For many facilities that treat clients under Medicare and/or Medicaid, payment adjustment programs such as Meaningful Use, MACRA / MIPS, and PQRS are an essential part of daily operations. Be sure to check with your billing and compliance departments to determine if you require an EHR that is certified, in order to participate applicable programs.

PIMSY was 2011 & 2014 Edition certified for Meaningful Use, and – now that Meaningful Use has been replaced by MACRA / MIPS – is in the process of becoming ONC-ACB 2015 Edition certified.

Take Away

If your facility treats Substance Use / SUDs, use the checklist above to find a behavioral health EHR that will best support the services & treatments offered. To see if PIMSY is right for your organization – or for details of the functionality highlighted above – contact us: 877.334.8512, ext 1 //


Jerica Rossi

Jerica Rossi

Jerica Rossi is a Marketing & Marketing Associate of PIMSY EHR. For more information about electronic solutions for your practice, check out Behavioral Health EHR.

Author: pehradmin