Electronic health records (EHR) were supposed to make care more connected, more efficient, more human. But for many clinicians, they’ve become the opposite: a new layer of friction between them and the work that drew them into this field in the first place.

And this isn’t an accident. Most EHR systems were built for medical settings, not for therapists: prioritizing billing codes and checkboxes over narrative nuance and clinical reasoning. Over time, therapists have adapted so thoroughly to these systems that many no longer notice the contortions required just to schedule a session, document a note, or submit a claim. The workflow friction has become invisible, woven into the background of daily practice. In subtle ways, clinicians have learned to accommodate the EHR instead of the other way around: reshaping their language, documentation practices, timing, and even thinking to fit a platform that was never really designed for them. In short, while the EHR may be indispensable, it’s also a mirror of the system’s most persistent imbalance: more time spent managing care than delivering it.

We live in an era where digital tools should free us to focus on clients, yet they often chain us to screens. So how did we get here? How did tools meant to lighten clinicians’ load become one of its heaviest weights? To understand the current fatigue and friction, we need to trace the evolution of EHRs, explore their impact on mental health care, and look forward to innovations that promise to restore the therapist’s time and focus. 

The EHR’s Early Roots: Paper, Patience, and the Push Toward Standardization

Before there were portals, dropdown menus, or endless login screens, there were binders. Stacks of manila folders lined office shelves, each one heavy with a client’s story: the handwritten notes done after sessions, treatment plans, intake forms, insurance correspondences, perhaps a stray sticky note with a reminder about medication changes.

Psychotherapy notes began to be formally kept in the early to mid-twentieth century, as the field professionalized and agencies sought clearer records for supervision, continuity of care, and later, insurance reimbursement. For much of that century,  mental health records were physical, private, and profoundly human, reflecting the intimacy of the therapeutic relationship itself. But they were also deeply fragmented. A therapist’s handwritten notes might never cross paths with a client’s primary care file, and even when they did, they may not have been legible. If a psychiatrist or social worker needed a client’s history from another provider, they’d submit a request to a hospital’s medical records department, where it could take hours, even days, for someone to locate the right folder and send it over. There was no centralized system to track incomplete documentation or outstanding notes–only the therapist’s own memory and file cabinet. Maintaining compliance also required physical space: rows of locked filing cabinets and storage rooms to preserve records for the legally required number of years. Communication across a care team was slow, compartmentalized, and at times, disconnected.

The first glimmers of a digital alternative emerged in the 1960s, long before most therapists would ever touch a computer. Early “clinical health information systems” were the stuff of research labs and government contracts, not counseling offices. The Lockheed Corporation (now Lockheed Martin) helped design one of the earliest prototypes for hospitals, however it was a system so costly and cumbersome that only large institutions could experiment with it. The Mayo Clinic in Rochester, Minnesota was one of the first to implement such systems, setting a precedent that data could, in theory, make care safer and more coordinated.

At around the same time, Dr. Lawrence Weed introduced a concept that would quietly change everything: the Problem-Oriented Medical Record (POMR). It seems almost quaint now, but this was revolutionary for the time period. Before POMR, medical records were often little more than scattered, chronological notes. Weed’s idea was to organize them by problem: each condition or concern had its own section and trajectory. It was a move toward logic, structure, and shared understanding. And although it would take decades for behavioral health documentation to follow suit, this was the foundation of what we now know as the EHR.

By the 1970s, the U.S. Veterans Administration (VA) took the next bold step, launching the Decentralized Hospital Computer Program (DHCP), which later evolved into Veterans Health Information System and Technology Architecture (VistA): a fully integrated system managing everything from medication orders to x-rays. VistA proved that digital records could make healthcare faster, safer, and more connected. By most accounts, it was the first real version of how systems share information today. But as with most government-led technological revolutions, it existed in a different universe than private practice (especially mental health care), which was still largely analog and independent.

Even as major hospitals and academic centers began experimenting with digital records, most therapy practices were priced out. The hardware was expensive, the software was proprietary, and the workflows felt incompatible to the human-centered rhythms of therapy. For most clinicians, the pen remained mightier than the microchip.

By the 1990s, however, a new force entered the scene: the internet. With its introduction, the promise (and threat) of digitization was everywhere. For healthcare in particular, that meant data could finally move easily across systems and geographies. But it also raised urgent questions about privacy and security. The 1996 Health Insurance Portability and Accountability Act (HIPAA) sought to answer those questions, introducing strict rules for protecting patient information. HIPAA not only standardized electronic transactions but also gave legitimacy to the idea that digital records could be trusted.

Still, the momentum for digitization wasn’t only about clinical care – it was about billing. Hospitals needed accurate, coded data to comply with insurance systems and new regulations. With their expansion beyond academic and large institutions into smaller practices, the first proto-EHRs that emerged in the 1990s and early 2000s were often glorified billing platforms, built to satisfy insurers, not clinicians. For mental health clinicians, this mismatch would echo for decades: systems designed for compliance first, not connection.

The Rise of EHRs: Technology, Incentives, and Uneven Adoption

By the early 2000s, healthcare had entered an awkward digital adolescence: too far in to turn back, but not yet functional enough to make anyone’s life easier. For most therapists, the promise of “better documentation through technology” remained just that: a promise.

Then came 2004, and with it, the Office of the National Coordinator for Health Information Technology (ONC): a government office tasked with bringing healthcare’s data systems into the modern age. The ONC’s ambitious mission: make EHRs universal.

That said, the real turning point came with the HITECH Act of 2009, part of the broader American Recovery and Reinvestment Act. Through the “Meaningful Use” program, hospitals and physicians could earn tens of thousands of dollars per provider if they adopted approved systems and demonstrated measurable improvements in care. The logic was elegant: if technology could prove it improved care, it deserved funding.

By 2015 it was clear the effort had worked. According to an 2016 report released by the Office of the Assistant Secretary for Technology Policy, hospitals had reached a staggering 96% adoption rate. Primary care, internal medicine, and specialty practices had officially entered the digital era

But here’s where mental health care, once again, stood apart.

Behavioral health providers were deliberately excluded from many of these federal incentive programs. While hospitals and medical practices received tens of thousands of dollars per provider to offset adoption costs, mental health clinicians (especially those in solo or small-group practices) did not. This exclusion was rationalized as a matter of “scope,” but its impact was stark. It wasn’t just a delay: that single decision reshaped the trajectory of mental health technology. 

Even though EHRs presented a whole system that failed to recognize and support the unique needs of therapists, insurance billing, regulatory documentation, and client expectations eventually made EHRs a necessity rather than an option within mental health care. Even without federal incentives, behavioral health providers were expected to meet modern documentation standards without ever receiving the same head start in infrastructure and support. 

What resulted was a digital landscape marked by asymmetry. While large hospitals implemented integrated systems like Epic or Oracle Health, most mental health practices turned to smaller, more affordable, purpose-built platforms designed to be “lighter,” but still prone to bugs, rigidity, clunky interfaces, and user frustration. By the mid-2010s, nearly every therapist had a login to something.

How EHRs Changed Care Quality and Outcomes in Mental Health

For all their frustrations, EHRs did bring measurable improvements to certain aspects of mental health care. Studies in the late 2010s and 2020s began to document better clinical coordination and outcomes associated with digital records — at least in theory.

For example, a 2019 study on schizophrenia care found that EHR use correlated with improved rates of preventive screenings and medication adherence (Ng-Mak et al., 2019). Another line of research showed that clinical decision support tools in primary care practices (features like drug interaction alerts or reminders for follow-up care) could reduce human error and improve continuity (Matthews, 2022).

In practice, this meant that a therapist in a hospital system might be automatically notified if a client missed a psychiatric follow-up, or if a medication dosage changed. This was a new kind of safety net that simply didn’t exist in the paper era: making it less likely for clients to fall through the cracks. Also, while often imperfect, this made collaboration between providers easier and more immediate.

Legacy EHRs now boast interoperability, note templates, client portals, billing integrations, and telehealth tools; all theoretically designed to make life easier for clinicians. But for many therapists, that promise feels only half-kept. The systems record, track, and automate – but they rarely understand how behavioral health clinicians actually work.

Perhaps that’s why, even in 2025, the conversation among mental health professionals still echoes that first tension from the 1960s: the tension between documentation and the therapeutic relationship. Legacy EHRs may have standardized documentation practices, but they also standardized something else: the therapist’s time, attention, and bandwidth. And as therapists continue to navigate their digital tools, they’re also carrying the structural burden of a system built for medicine, not for mental health.

The Features and Limits of Legacy EHRs

If the history of the EHR is a story of aspiration, the present is a story of compromise. For all the promise of technology, most therapists today interact daily with systems that are simultaneously indispensable and exhausting.

Their advantages are clear: standardized documentation, insurer-compliant billing, and centralized records – but they often feel built for administrators rather than therapists. They all store client data, provide billing functionality, and help clinicians comply with insurers and state documentation requirements. They allow scheduling, track progress notes, and sometimes even integrate telehealth functionality. Without them, running a mental health practice would be nearly impossible: insurance reimbursements would stall, records would scatter, notes would get forgotten, and the painstaking task of proving medical necessity would remain a paper chase. And yet, many therapists describe these systems as clunky, counterintuitive, and misaligned with clinical work. Let’s take a closer look at some common challenges: 

Rigid, Clunky Interfaces

Unlike hospital systems designed for large, multidisciplinary teams, legacy EHRs were often retrofitted from general medical models – which means that they scale down poorly for solo or small-group practices. That is in part because the templates, prompts, and workflows built for primary care do not always translate well to the subtleties of therapy. 

These challenges come from both the way the system is built as well as how flexible it is to use. Many legacy systems are rigid, offering limited customization. Drop-down menus, fixed templates, and rigid CPT and ICD-10 code structures can make documentation feel like filling out a time-consuming government form rather than capturing the richness of human experience. 

Workflow Disruption

Mental health notes, treatment plans, billing, scheduling, and client communications are spread across tabs and require excessive clicks. Tasks intended to take minutes can consume hours when they’re all added together, spilling into evenings and weekends. A 2022 review published in the Journal of Medical Internet Research found that poorly designed EHR templates disrupted information workflows in mental health contexts, highlighting the tension between system requirements and clinical work (Kariotis, et al. 2022). 

Furthermore, the process of keeping up with mandatory updates, coding changes, and compliance requirements adds a continuous background noise that consumes attention and energy. There is a quiet but damaging mental toll of navigating alerts, pop-ups, and reminders during the clinical day that can subtly feed into clinician burnout and erode the quality of patient interactions.

Poor Useability

Clunky navigation, excessive clicks, lack of customization can make tasks more difficult to complete. That’s in part because as new technology has become available, legacy EHRs have grafted new functionality on as it becomes needed, making the entire experience feeling clunky and haphazard. Legacy EHRs force a full session workflow (write progress note,, confirm the correct procedure code and modifiers, submit a claim, collect and record payment, send follow up resources to client as discussed in session, update treatment plan and goals as needed, schedule the next session, send client a reminder for the next session) into dozens of clicks, spread across tabs. As any clinician would attest, therapists don’t have time to spare between sessions, so the work piles up at night or on weekends.

The amount of time required for data entry and documentation can be quite substantial especially for mental health professionals with larger caseloads. EHRs require alertness and focus which can cause cognitive fatigue over time. The time spent working with EHRs is often unaccounted for and undervalued. This could lead to extension of the planned client hours and a rise in stress or burnout. 

Integration Gaps

In part because legacy systems were built as standalone applications, they do not integrate well with modern tools for billing, telehealth, patient engagement software, and other practice management functions. What’s worse, these integration gaps are sometimes intentional: purposefully not compatible with other systems so that legacy systems can build their own equivalent tools and charge additional fees for their usage.

Increasingly Expensive Subscriptions

EHR systems were once sold as the fix-all for modern practice: one platform to manage notes, billing, and client care. But today, they resemble something more like a patchwork project: billing tools added on here, telehealth extensions layered there, although the video is often glitchy so best to keep a separate subscription for this. Need analytics? That’s an added-on fee. Want AI-assisted note-taking? That’s another. What started as a unified system has splintered into a collection of costly, loosely connected features.

Technology was supposed to make clinical life smoother—and sometimes it does with automated scheduling, fewer billing errors, and faster charting than handwritten notes. But for many therapists, the promise has come with new headaches. Each additional feature brings another subscription fee, as well as another layer of technical upkeep. The tools designed to save time can easily start consuming it, leaving clinicians managing not just clients, but an ever-growing tech stack.

Consider the numbers: SimplePractice raised its base plan, which does not include basic benefits like scheduling reminders, from $39 to $49 per month in 2024. Therapy Notes announced they are raising their solo plan from $59 to $69 per month in December 2025. As of November 2025, AI note-taking tools like Freed can cost about $90 per clinician each month, and JoyPsych $149 every month. Add in telehealth platforms, secure messaging systems, and compliance software, and a solo practitioner might pay $400–$600 every month just to stay operational online. For many, that’s not innovation—it’s overhead dressed up as progress.

Despite these frustrations, there are also glimpses of what legacy EHRs have done well. When and where available, billing integration ensures faster reimbursement, superbills can be created in seconds, structured note templates make audits more manageable, and patient portals offer clients access to secure messaging and scheduling. But these benefits often feel tethered to the requirements of administrators and insurers, rather than the needs of therapists or the experience of care itself.

What Comes Next: Therapist-Centered EHRs

If the story of legacy EHRs is one of compromise, the future promises realignment with the clinician’s workflow and the client’s experience. Technology is catching up, and for the first time, we’re seeing systems designed with therapists in mind, not just for insurers.

The goals are clear: save time, reduce cognitive load, and enable clinicians to focus on client care. AI is poised to transform EHR functionality. This next generation of EHR systems can draft progress notes from session recordings, flag key clinical trends, automatically check for insurance compliance, adjust scheduling automatically – all while leaving clinicians free to focus on therapy itself. 

User-centered design is another hallmark of next-generation systems. Rather than forcing clinicians to conform to rigid templates, these EHRs offer flexible note structures, integrated telehealth platforms, customizable workflows, and context-aware prompts. Clinicians can capture narrative detail where it matters, while the system ensures billing, coding, and compliance requirements are met automatically. By integrating administrative and clinical assistance, AI tools can reduce the friction therapists experience when switching between cognitive and clerical tasks.

Another advancement is decision support systems tailored to mental health care. Unlike legacy alerts that primarily flag billing errors or missing documentation, these tools highlight clinically relevant issues: trends in symptoms, completed assessments and worksheets, or missed sessions. They act as a safety net, catching details therapists might miss in the whirlwind of sessions, scheduling, and administrative tasks.

This new era of practice support systems and smarter EHRs recognize the emotional and cognitive load of therapy itself. Features such as template suggestions, automated reminders, and pre-filled insurance forms are designed to reduce cognitive friction, leaving clinicians able to focus on nuance, empathy, and connection. This is a subtle but profound shift: for the first time, the technology is working for the therapist, not against them.

The rise of AI and therapist-centered design reflects a broader recognition: digital tools must be flexible, adaptable, and responsive to human patterns of clinical reasoning, not just to billing compliance.

Of course, the adoption of these new systems will not be seamless. Change is always difficult, and those who have spent decades navigating clunky interfaces may resist even the most user-friendly solution. Yet, it’s clear that the EHR needs to change. And the trajectory is clear: the EHR of the future will be a partner, not a burden. One that aligns with the pace of human attention and the subtleties of therapeutic practice, rather than demanding that humans bend entirely to its logic.

The trajectory toward smarter, therapist-centered EHRs also signals a broader philosophical shift. For decades, technology has been top-down: designed for administrators, regulators, and insurers. Now, it is increasingly ground-up, informed by the daily experiences of clinicians, the rhythm of client sessions, and the practical realities of practice management. 

In practical terms, the implications for therapists are transformative. Less time spent wrestling with forms means more time for clinical reflection, supervision, and client engagement. Fewer interruptions for documentation mean more continuity in sessions and less cognitive fragmentation. And, perhaps most importantly, the EHR begins to feel like a tool that respects the therapist’s labor, rather than one that undermines it.