Electronic Health Records: Eliciting Behavioral Health Providers’
Nancy Shank•Elizabeth Willborn•
Lisa PytlikZillig•HarmoniJoie Noel
Received: 31 March 2010/Accepted: 25 April 2011
? Springer Science+Business Media, LLC 2011
health providers elicited perceived benefits and barriers of
using electronic health records. Themes identified were
(a) quality of care, (b) privacy and security, and (c) deliv-
ery of services. Benefits to quality of care were mentioned
by 100% of the providers, and barriers by 59% of pro-
viders. Barriers involving privacy and security concerns
were mentioned by 100% of providers, and benefits by
22%. Barriers to delivery of services were mentioned by
97% of providers, and benefits by 66%. Most providers
(81%) expressed overall positive support for electronic
behavioral health records.
Interviews with 32 community behavioral
Healthcare provider beliefs ? Qualitative methods
Electronic health records ?
The American Recovery and Reinvestment Act (2009)
directed billions of federal dollars to accelerate the wide-
spread adoption of electronic medical records (EMRs) and
electronic health records (EHRs).1Most of the funding and
attention has been directed toward medical providers,
and little is known about how community mental health
and substance abuse providers view using EMRs or EHRs.
This lacuna is surprising because behavioral health issues
(i.e., mental health and substance abuse) are prevalent and
costly, and are an important component of an individual’s
health information (US Department of Health and Human
Services, Agency for Healthcare Research and Quality
2009). The purpose of this exploratory, qualitative study
was to elicit community behavioral health providers’
beliefs about the benefits and barriers of using EHRs. The
conceptual framework for this study was the theory of
reasoned action which suggests that understanding beliefs
aids in predicting behaviors (Ajzen and Fishbein 1973).
Provider Perceptions About Electronic Records:
Benefits and Barriers
We located only three studies focusing on behavioral
health providers’ beliefs about EHRs or EMRs. All three
obtained information through structured surveys or inter-
views. The first, a post-implementation survey of psychi-
atric clinicians using an EHR, focused on nine benefit
and barrier categories: data security, data sensitivity, data
quality erosion, data quality enrichment, xenophobia,
altered recording behaviors, comfort with security, effi-
ciency, and importance of confidentiality (Salomon et al.
2010). In the second study, behavioral health providers
believed there were benefits to using EMRs and having
interoperability with medical/primary care systems, but
also perceived cost as a significant barrier (Lefkovitz
2009). The third study surveyed providers at an Australian
mental health organization and found that providers
believed EMRs made their job easier and more efficient,
improved client care, improved communication with other
staff, and were effective for documenting and accessing
N. Shank (&) ? E. Willborn ? L. PytlikZillig ? H. Noel
University of Nebraska Public Policy Center, 215 Centennial
Mall South, Suite 401, P.O. Box 880228, Lincoln,
NE 68588-0228, USA
1We follow Garets and Davis (2006) in using electronic medical
record (EMR) to mean the legal record created and used by a
healthcare organization primarily for use within the organization, and
electronic health record (EHR) to refer to client information that
combines EMR data from multiple healthcare providers.
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client progress and staff activity (Walter et al. 2000). We
were unable to find any studies that elicited qualitative
belief statements generated from behavioral health pro-
viders themselves, but instead only found these that used
researcher-defined belief statements. Because behavioral
health providers’ views have important implications for the
adoption of EHRs in community mental health services, the
goal of the present study was to fill that research gap and
explore behavioral health providers’ beliefs about the
benefits and barriers of EHRs.
Sample and Participants
Participants were recruited from a list of all behavioral
health providers practicing in a 16-county urban and rural
region of Nebraska. The provider list was stratified by type
of provider role: (a) psychiatrists, advanced practice reg-
istered nurses, and physician’s assistants; (b) psychologists;
(c) licensed mental health practitioners; and (d) registered
nurses. The list was randomized within the roles and
potential subjects were invited by phone to be interviewed.
The recruited sample (n = 32) was: middle-aged, with
65% between 41 and 60 years of age; highly educated, with
almost half (47%) having doctorates (i.e., M.D., Ph.D., or
Psy.D.) and another 20% having masters degrees; slightly
male (53%); and practicing in both public as well as private
settings. The participants reported using practice-related
technologies: 50% of the respondents reported regularly
using EMRs within their organizations and nearly one-third
reported regularly using lab systems. The survey did not
ask about EHR use. A majority reported using fax (91%),
phone (88%), or mail (72%) to exchange client data with
providers at other facilities.
Measures and Procedures
A semi-structured interview protocol was designed to
probe providers’ beliefs about the barriers and benefits of
EHRs and how such sharing would affect clients, providers
within their organization, and providers outside their
organization. The four focal interview questions were:
(a) What would be the benefits of a system that allows
providers to electronically exchange client behavioral
health information with other health care providers,
(b) What would be the barriers to using a system that
allows providers to electronically exchange client behav-
ioral health information with other health care providers,
(c) Who in your organization would you rely on to be part
of the decision-making process regarding adopting and
implementing an electronic system for behavioral health
information, and (d) What is the likelihood that you and
others in your primary practice or organization would use
an electronic sharing system if it were developed?
Interviews with providers totaled 16 h, with a mean
length of 29 min. Interviews were transcribed and coded
over a 10-week period of time. Four researchers worked
independently to code the data using Atlas.ti software and
met weekly using a reiterative, inductive approach to
determine agreement on coding terms and clusters, and to
identify the codes that comprised major themes. Reliability
was then assessed by computing the presence of double-
coded inter-rater agreement themes for four randomly
selected interviews. Coders achieved 100% agreement in
coding those interviews for the presence of the three major
themes. The study was approved by the University of
Nebraska-Lincoln Institutional Review Board.
Interviews about the benefits and barriers of EHRs revealed
three major themes: (a) quality of care, (b) privacy and
security, and (c) delivery of services. For each theme area
we present benefits and barriers, in sequence, according to
which was more frequently mentioned by providers.
Theme 1: Quality of Care
In the interviews, all 32 providers mentioned that EHRs
would result in benefits to quality of care for clients,
whereas only 19 providers mentioned there were quality of
care barriers. All providers expected that EHRs would
provide more complete and immediate information that
could improve quality of care. Comments included:
– Continuity of care is a main part of all of this. Because
everybody gets to know what is wrong with the
patient… and if the primary care provider can get the
information just like the psychiatrist then it is better
treatment for the patient.
There are so many more variables that could be causing
the person’s behavior. That’s why coordination is
There’s a disruption of care because you have to wait a
half hour while we’re trying to contact the hospital and
having the hospital fax over information… It can be
several months before we get [the information].
Approximately half of the behavioral health providers
mentioned that medication information would be particu-
– If [the client] has a heart condition…there are going to
be certain medications we want to avoid. General
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physicians should have [mental health] information
because there’s a lot of medication they give that may
make a person quite depressed.
Just having a record of what’s working for them would
be a great benefit instead of starting over.
One-quarter of the behavioral health providers stated
that having more complete information would save time for
clients and would increase their satisfaction with services:
– We go over the same old ground that the patient has
disclosed to other providers. They [have to] say the
same thing to ten different people.
More than one-half of the providers also expressed EHR
barriers. The most frequent concern, voiced by 10 pro-
viders, was that EHRs could result in miscommunications
with other behavioral health and medical providers:
–It’s not face-to-face, so there always can be miscom-
munication because of that.
– If you have major depression, once that’s down there
someplace, then every time somebody looks to see
what the diagnosis is, they just transfer that to the next
health form that it’s on, even though those things may
be only very temporary.
One-quarter of the providers indicated that provider–
client relationships would suffer if EHRs required them to
divert their attention from clients to their computers:
– If I’m spending all of my time looking at my keyboard,
typing as I’m interviewing you, that really cuts into the
relationship that we’re supposed to be developing.
In summary, all providers mentioned quality of care
issues. Some providers even commented that improved
quality of care for the client should be the primary moti-
vation for adopting EHRs:
– The only reason for exchanging would be for the
maximum benefit of different people having different
areas of expertise, medical, versus psychiatric, versus
nutrition that contribute to the whole of treating an
individual… There would be no reason to exchange
information with somebody that wasn’t potentially
going to be helpful in treating the client’s overall needs.
Theme 2: Privacy/Security
All 32 providers mentioned privacy and security con-
cerns as barriers to EHR use, and only 7 mentioned
EHRs would provide privacy and security related bene-
fits. Nearly all of the providers identified general privacy
and security concerns as the single most important bar-
rier to adopting behavioral EHRs:
Confidentiality is always the most important factor.
The biggest drawback is… that data [are] being
compromised or shared in inappropriate ways or
reaching the wrong person.
Over one-third of providers stated that they believed
clients would be reluctant to consent to electronic sharing:
–Patients are legitimately concerned about what happens
to their health care information.
They get worried about the CIA and FBI and other
agencies spying on them.
Just under one-quarter of providers stated that they
believed that federal privacy regulations and other legal
issues were barriers:
– HIPAA. HIPAA, HIPAA, HIPAA. That’s about the
first three or four problems in the way.
I’m the one whose hide is on the line if confidentiality
One-quarter of the providers predicted that EHRs would
offer improvements, particularly in comparison to current
procedures for information sharing:
– I call Walgreens and I say, ‘‘I’m an RN from this
hospital, and I need to verify John Smith’s meds.’’
Well, Walgreens doesn’t know who I am, [yet they
provide patient information over the telephone].
If I hit the wrong number, is that fax going to go to the
wrong place? Then I have confidential information
going where it shouldn’t go.
In summary, providers mentioned privacy and security
barriers more than they did privacy and security benefits.
As one provider summarized:
–Anybody is going to be concerned about security issues
because paper can be easily accessed, but only by a
limited number of people. Anything that’s computerized
may be harder to access but can be accessed by millions
of people. So you probably have a higher degree of
difficulty but a wider scope of who could get to it.
Theme 3: Delivery of Services
The final theme salient to behavioral health providers was
related to delivery of services. Providers discussed delivery
of services barriers more than they discussed the benefits:
97% of providers offered at least one barrier and 66% of
providers offered benefits. Three-quarters of providers
noted that staff reluctance would be a barrier:
–Some people are very good physicians or very good
nurses or therapists but the moment they see a
computer they freeze.
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–A lot of providers in mental health have just very rigid
ideas about exchanging information and being overly
protective of client information, and I think that that
would only add to their overprotectiveness.
Three-quarters of providers were concerned that EHRs
would be too costly and time consuming to implement and
Cost, number 1? Yeah.
[EHRs] would be laborious for me to have to input
information electronically to be able to send it…I do all
my clinical work and all of the secretarial work.
The efficiency of the system depends on every person
being able to use or wanting to. If 10% people are
resistant…then it becomes an inefficient system and
you still have to do a paperwork system in addition to
Finally, more than half of providers were skeptical that
EHRs could accommodate the narrative-rich nature of
behavioral health information and believed that computer-
based systems would not be reliable:
– You can’t template someone’s psychological history.
You can’t do that.
I’ve had multiple times where I’ve done an assessment
and I’m almost done and the computer crashes… And
I’m ‘‘Okay I have to start this all over. You’ve got to be
Despite these negative comments, approximately two-
thirds of the providers stated that EHRs might also offer
benefits, particularly in time and cost savings for them-
selves and their practices:
– It saves me time… We’re not chasing each other on the
phone; we’re not sending emails back to each other
saying, ‘‘Hey, do you think I can get this information?’’
Patients’ needs can be exchanged before the visit starts
so care can be provided in a more efficient way.
In summary, providers offered differing beliefs about the
impact of EHRs on practices. Most providers were worried
that it would be too costly for them to implement and use:
– When you’re talking about mental health you’re talking
about small offices. You’re talking about providers who
cannot handle large overhead which electronic systems
tend to bring into the overall expense of an office.
Overall Attitudes Toward EHRs
During the interviews, providers were also asked to rate
their overall supportiveness toward EHRs. Most stated they
had a positive attitude toward EHRs. Of providers who
summarized their overall opinion, 81% characterized
themselves as positive, 12% characterized themselves as
having an overall negative opinion, and 8% characterized
themselves as both positive and negative. When asked
whether they believed that behavioral health information
was different from medical information, most providers
(59%) said yes. Of those providers, most (79%) stated that
behavioral health information is more sensitive and the
client more vulnerable. Some providers (32%) noted that
the subjectivity of behavioral health information makes
electronic sharing a more complicated process.
The purpose of this study was to identify community
behavioral health providers’ beliefs about the barriers and
benefits of EHRs. Behavioral health providers’ responses
clustered into three themes: (a) quality of care, (b) privacy
and security, and (c) delivery of services. Among the
benefits discussed, all providers mentioned quality of care
benefits, two-thirds discussed delivery of services benefits,
and fewer than one in ten discussed privacy and security
benefits. Of the barriers, privacy and security concerns
were mentioned by all providers, nearly all providers
mentioned delivery of services barriers, and over half the
providers cited quality of care barriers.
Although behavioral health providers expressed con-
cerns about possible barriers to adopting electronic records,
a majority (81%) characterized themselves as having a
positive attitude toward electronic sharing. This positive
attitude has implications for the adoption of EHRs for
community mental health services: Providers who have
positive attitudes about adopting EHRs may be likely to
adopt (Ajzen and Fishbein 1980). Further research is nee-
ded to determine whether these findings are representative
of the larger population.
The present study found that behavioral health providers
believe EHRs may compromise client privacy: 100% of
behavioral health providers voiced concerns about privacy.
This is consistent with other behavioral health studies and
testimonies (Cost and confidentiality 2008; Privacy and
confidentiality 2005; Salomon et al. 2010; US Department
of Health and Human Services, Office of the Surgeon
General 1999). This result differs from qualitative studies
of medical providers, none of which identified privacy and
security as a unique issue (Austin et al. 2006; Miller
and Sim 2004; Scheck McAlearney et al. 2004). Privacy
and security issues also were not identified as a major issue
in surveys that explicitly included questions to assess
physician concerns about privacy and security (Gans et al.
2005; Penrod and Gadd 2001; Wright et al. 2010). Thus, it
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appears that privacy and security is a greater concern for
behavioral health providers than for medical providers.
In the present study, cost and increased staff time were
frequently mentioned as significant barriers to adopting
EHRs. Just as smaller medical practices have much lower
face challenges based on their size. Well over half of all
psychiatrists and psychologists report an individual practice
as their primary or secondary employment setting (Duffy
et al. 2004). Cost saving approaches, such as shared com-
puting services, may be needed to make EHR technology
financially viable for behavioral health providers. Although
it is not known what an acceptable cost for behavioralhealth
providers may be, a recent study of medical providers found
that most were unwilling to pay a suggested hypothetical
fee of $150 per month (Wright et al. 2010).
The present study design employed an inductive quali-
tative method which was well suited to identifying the
range of issues from the perspectives of the participants
themselves, rather than limiting responses to those deter-
mined as important by the researchers. This approach is
particularly useful when researchers want to elicit partici-
pant beliefs (Ajzen 1991). Further research is needed to
confirm and extend the initial themes identified in this
study. Future research could also focus on the influence of
personal and practice characteristics on beliefs. For
example, providers in our sample reported a high use of
EMRs (50%). Past studies have suggested that providers
who use EMRs tend to focus on the benefits of the systems
more than the barriers, as compared to providers who have
not implemented EMRs (Gans et al. 2005; Scheck McAl-
earney et al. 2004). Other studies have found that practice
setting and size are factors in physician acceptance of
EMRs (Audet et al. 2004). It is an open question whether
patterns such as these will be found among behavioral
In conclusion, three themes (i.e., quality of care, privacy
and security, and delivery of services) were identified from
interviews with 32 behavioral health providers. Most
behavioral health providers had positive beliefs about
sharing client records electronically. This exploratory study
adds to the existing literature on EHRs by showing that
some barriers (e.g., privacy and security) are of greater
concern to behavioral health providers than to medical
providers. This has useful implications for community
health providers adopting EHRs. The results suggest the
ultimate challenge to behavioral health EHR adoption is
whether quality of care benefits valued by providers may
be achieved, while ensuring confidentiality of client
authors and does not necessarily represent the official views of the
The content is solely the responsibility of the
Agency for Healthcare Research and Quality. This project was sup-
ported by grant number R18HS017838 from the Agency for Health-
care Research and Quality.
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