Sunday, December 11, 2011

Not in My Record!

For a while now we've been talking about issues related to psychiatry and electronic medical records.  Roy is very interested in the evolution of EHR's.  

I don't like them.  I think they have too many problems still, both in terms of issues of efficiency and time, and how they divert the physician's attention away from the patient, and they focus medical appointments on the collection of data-- data that is used in a checkbox form: patient is not suicidal and I asked, whether it was clinically relevant or not-- and will therefore serve as protection in a lawsuit, or demographic information used by insurers, the government, who knows.

From a privacy standpoint, I think they are appalling.   If you are a patient in the hospital where I work, you get no say, your info goes in to the electronic record and everyone who treats you can access it.  And anyone else who uses the medical record in the hospital can access it as well; the "check" on the system, since much of our city is treated at this hospital, is the after-the-fact threat/fear of being fired or disciplined for looking at someone's record you shouldn't.  I believe the check should be before the fact-- that a patient should have a code, or PIN number they punch into the system that unlocks the system for that particular healthcare provider.  Or something akin to that.  

But what about the fears that people express on our comments that they will be judged and dismissed if their doctors know they've seen a psychiatrist or taken a psychotropic or been hospitalized?  On one hand, there is the idea that this information is more sensitive and should be protected, so that psychiatry records have traditionally been kept out of EHRs.  On the other hand, there is the belief that calling them "sensitive" further stigmatizes psychiatric disorders and it's time to treat them like every other medical problem.  

I will tell you that last year when we did a survey of Attitudes Towards Psychiatry, 41% of respondents thought psychiatry records should not be segregated.

Electronic Health Records (EHRs or EMRs) . . .
should not contain any records of psychiatric illnesses and treatments (including medications) even though that means my primary care doc or ER doc wouldn't know about my meds or condition unless I tell them
should have separate and higher protections for mental illness than for other health problems
should exist for psychiatry exactly as all other medical records do, with the same protections as for other health condition, because adding special protections increases stigma against mental illness
should allow patients to control which information they wish to be shared and with whom for all medical specialties
facilitate better communication and improve psychiatric care
negatively affect communication and detract from psychiatric care
I have no significant opinion about electronic health records in psychiatry
People may select more than one checkbox, so percentages may add up to more than 100%.
Your thoughts?


Liz's Blog said...

all of these electronic records, as a whole, sort of frighten me. i know how nosy people are. and i don't want anyone who doesn't have a NEED to know to know anything about my psychiatric history.

i wish i could start over. my whole medical record.

unfortunately, there seems to be no way to escape it.

Anonymous said...

I just moved to a new city and am in the process of selecting a PCP. When I call the prospective doctor's office, I ask about EHRs. The modality makes me nervous.
Also, I am newly diagnosed with bipolar disorder. I do take lithium. My former PCP was cold and rude. I am not convinced this was because she is naturally cold and rude. I am beginning to believe the bipolar diagnosis had something to do with her cold and rude behavior. As a result, I am considering not telling the new PCP anything about bipolar and lithium.

What do I do if the best medical care requires EHRs and is connected to a hospital system that I will be launching my new career from? Somehow, the after-the-fact peeping threats of job termination do not provide enough reassurance that I will not be "outed."

manchester fat acceptance said...

i don't have a problem with the idea of physchiatric EHR - i don't like having to repeat myself to every health professional so it would save time and energy. however, i live in Canada where some things are less of an issue (i.e. no worries about HMOs and such accessing my medical records, if i have that detail correct).

CatLover said...

I must admit that I have rarely been treated poorly by general doctors or their staff, because of the bipolar diagnosis. But I worry about it.

I know that my mother in law was not treated for colon cancer for months because her HMO doctor said all her pain was due to "anxiety." My mother in law was a smart, well spoken lady (but anxious) and I can see the same thing happening to me someday. My mother in law's mistake was that she should have paid out of pocket for her care, and not waited for diagnosis and treatment while arguing with the insurance company. She would have died anyway, but due to her anxiety diagnosis, she suffered very much due to the large tumor.

I also wonder if the reason a doctor accused me of drug-seeking behavior after a surgery had anything to do with bipolar in my chart. The pain meds made me puke, and the second thing I was given also made me puke. Instead of suggesting what to do, the doctor accused me that I was a drug abuser (which I have no history of drug abuse). This was before the Internet, and I didn't know what to do, and took aspirin, a poor choice after a surgery (but it worked great). Now maybe bipolar in the chart made the doc suspicious, or maybe he was just suspicious anyhow.

It's possible that I don't usually run into problems with family doctors because I rarely go to the doctor. And if I have a cat bite or plantar fasciatis, that is so straightforward that no doc is going to treat me like I am a basket case.

I can't see how EMR's will help a psych patient who is trying to "pass for normal." It's just like if you posted something stupid on the internet - it's there forever. Is it going to be even harder to ditch a mistaken diagnosis? Or will it be easier? How about all these foster kids who get a wrong bipolar diagnosis and take antipsychotics for a few years, then it turns out they never had a problem to begin with, except for coming from a horrible background?

Anonymous said...

I really am uncomfortable with the EHR's in regards to my MDD or any notes my Doctor has wrote. People are nosy, just because your not supposed to look doesn't stop some people! The VA has thier Mental Health records locked to all but the Mental Health dept, and I think all MHR's should be set up like this. Maybe I am paranoid but I don't think so

Dr. Psychobabble said...

I continue to believe that preventing access to the psychiatric records by other docs (like the system at one of the hospitals I work at does) because it could be stigmatizing, paradoxically serves to perpetuate the stigma. Yes, there may be some docs/healthcare professionals who do judge a patient because they have a psychiatric history, but I don't think that preventing them from accessing this information serves to reduce that stigma...

Jen said...

Yes, and 43% thought patients should be able to control which information is shared with which physician.

Anonymous said...

I personally would not talk to a psychiatrist who uses an EMR that is accessible by other physicians. Like it or not stigma is alive and well in the health care field, and I'm not interested in being a martyr for the cause.

Now, that I don't share previous psych history I am treated much more respectfully by the physicians I see. I can tell a definite difference.

To those who are ok with all their physicians having access to psychiatric records, that's fine and their business. But, I like that I can keep psych records private and I'm glad I got out before I had no choice in the matter.

CatLover said...

Dr. Psychobabble, you are asking patients to risk individually being harmed for the sake of the group of all people with mental illness. I think that should be a person's choice to "out" themselves for a cause, not have it forced upon them. People with serious mental illnesses are LESS able to handle being treated poorly by others - they have already had plenty of that, or they wouldn't have mental illness, very generally speaking (obviously there are exceptions).

Anonymous said...

Dr Psychobabble, I can't help but wonder if your views might change if they were your psychiatric records. I would be willing to bet there are very few (if any) psychiatrists who would be okay opening up their own psychiatric records to other physicians if they had something like "borderline" or some other stigmatizing diagnosis in their medical records. I've seen the eyes roll when physicians and nurses have seen those diagnoses on a patient's chart, even by other by other mental health care professionals. No thanks.

jesse said...

Just to address one point that Dinah made: the growing emphasis in interviews and exams on the collection of data. In addition to the privacy concerns a major problem is that the data is often just plain wrong. The checkbox reduces complex, subtle information to basic blocks that are then used to justify treatment. It can be that the doctor knows what kind of treatment may indeed be helpful and then has to check off the boxes that justify it.

Either way, it is a problem. The fact is that psychiatry is not anywhere as scientific and precise as diagnoses would imply. Between the incorrect checkboxes, the need to protect oneself and the institution from legal action, and the importance of finding a reimbursible disease, the art of careful observation and judicious response is being lost.

That all of this incorrect data is searchable adds to the problem.

Anonymous said...

The Anonymous Internist, again
I am disturbed by the thought that psychiatric records can be read by all, although in my hospital, if the psychiatrist is consulted, her note is visible to all. In general, the consultations are for drug over-doses...and that's going to be "discoverable" through the ER visit alone.

I hate the genesis of the current progress note. Data (labs, radiology, path) should be owned by the is their data. However, whether "medicine" (and here are refer to internal medicine and it's specialties primarily) or psychiatry, the diagnosis is usually an interpretation of that data. As pointed out by Jesse, in psychiatry, the diagnosis in psychiatry is much more a subjective process.

Back in the olden days, the progress note was really for the physician only - a means to record impressions for the physician and other's involved in the patient's care. The notes were cryptic at times with many abbreviations, and the consulting colleagues were sometimes unable to decipher the notes. Then, the notes became a means of billing. Primarily through the billing regulations for medicare, we were forced to document certain elements to bill at certain levels. With that, un-needed information entered the note in order to be paid. Now, with the EMR, the entry of totally irrelevant information has been facilitated by technology. The definition of "meaningful use" has regulated all sorts of "clicks" that do nothing to help me take care of patients, decrease efficiency, and make the progress note less about communicating a physician's impression (diagnosis and plan) and more about fulfilling regulatory mandates.

Because the progress note is now at billing and fulfilling regulatory mandates, the meaning is lost. Because there is an idea that the patient "owns" the physician's impression and can see all progress notes, much information about a physician's impression is no longer placed in the note. The progress note has become an empty (but very large) shadow of it's former self.

Psychiatric labels can be damaging. Because universal access to facilitate care and privacy can not co-exist, I think there is a huge danger. Although it would be nice to think that allowing access will decrease stigma, I think it will decrease patient access for some people.

Unknown said...

There are many benefits and risks about electronic records, and anyone who has ever had to coordinate care among two or more providers will understand the benefit of coordination, and perhaps the risk of not knowing for sure who knows what. (See HIT Shrink post)

@anon #1: You might want to instead avoiding docs who discriminate or have attitudes against people with psych problems. Lithium is a great drug for many, but has very risky drug interactions. Not telling your doc about it raises the risk of these dangerous interactions, as well as other medical problems that the doc may have otherwise picked up on if she knew you were on lithium. This may mean checking out a few docs or asking around at a bipolar support group which docs are good, but the pay-off is worth it.

@catlover makes some great points. I have seen some docs become overly concerned about "drug-seeking", possibly because of a psych history. But the good @dr is right: treating psych records as extra-special adds to the stigma. ALL health records should be treated confidentially.

And, @anon#2, in the US we all have a right to request an accounting of anyone who has looked at your record. HIPAA requires it. Know your rights and exercise them.

Last @anon, good review on history of progress notes. Patients should be able to control who accesses their records. EHRs should be able to provide that ability to control and monitor access. When this happens, a doc will be more sensitive about writing comments in your chart that were really only intended for himself.

The best model I've seen is where docs have a large screen monitor in the room and create their note in front of the patient, which engages the patient and encourages them to ask questions and participate. Google "opennotes".

Unknown said...

Also, check out this 90 minute video of a recent Senate hearing on EHR security. The Office of Civil Rights is cracking down on lax security and people who look at health records inappropriately.

Anonymous said...

All I can say, Dr. Daviss, is that I feel very relieved I stopped seeing a psychiatrist when I did. I ended all medical care at a health care facility when i learned that psych records were being made part of their general medical record. I wasn't the only one who did so or the only one who felt violated. The consent was very vague about this and many, like myself, did not realize this was happening or we wouldn't have opened our mouths.

It is a huge violation of privacy to put psychiatric notes including psychotherapy notes in the general medical record, and it did impact the treatment I received from other physicians. I had the distinct pleasure of having some snarky comments made by another physician treating me for a non-psych issue thanks to the psychiatric notes. The argument by the facility was that they did this in the interest "holistic care." As I pointed out to them, it's not very holistic if people discontinue all medical treatment because their privacy was compromised. Interestingly enough they made the same argument that medical records are confidential. It's not confidential if every nurse I encounter, the dermatologist, and on and on has access to my psych records. Sorry, but the family practice physician doesn't need to know if my parents are together or divorced to treat an upper respiratory infection.

I think the more you guys do this, the more people will decide as I did to cease all psych treatment. It will only take a couple of snarky comments and that will be the end of it. Now, I go to facilities who do not have and will never have my psych history. I would never seek any medical treatment except in a case of an emergency if I could not keep psych records out of the general medical record.

jesse said...

One of the problems here is the setting in which the EMRs are done. For Dr. Daviss, who works in a general hospital, the importance of being able to see other clinicians' notes is clear, but is different from that of a clinician in a mental health facility, or a private practitioner. My concern is that rules crafted, for instance, to meet Medicare guidelines will end up applying to all clinicians in all settings.

As a private practitioner I am very concerned about the imposition of anything that would compromise confidentiality. Recently I was at a conference where this issue came up and the advice was given to simply not put certain things in the record, i.e. keep a second set of notes if need be that is not part of that record. Of course there can be major legal problems with this approach as should be obvious.

Anonymous said...

I think maybe I was a bit hasty in my response to Dr. Daviss. I missed his comment that patients should have the right to control who accesses their records. That I agree with. So, if a patient is comfortable with their dermatologist and every other nurse, physician, etc who touches their medical records knowing every intimate detail they shared in confidence with a psychiatrist, then I have no beef with that. That should be their right to disclose what they want. I just want the ability to opt out of that plan.

I really think having one big medical record will also make it even less likely that health care professionals will seek mental health care.

Anonymous said...

I agree with the many above psych records and notes should not be made available to ALL. Just recently went to a PA for meds and wonder if I decide to apply for a position (nurse) will my name be typed into the system to see if they have any information and will this effect my ability to get a job at the facility or any facilities related to this one.....

Anonymous said...

I agree with the many above psych records and notes should not be made available to ALL. Just recently went to a PA for meds and wonder if I decide to apply for a position (nurse) will my name be typed into the system to see if they have any information and will this effect my ability to get a job at the facility or any facilities related to this one.....

BPLadybug said...

I was rushed to a new hospital last month. My symptoms suggested stroke. My GP is part of a network which uses electronic records, and this hospital also had access. The ER doctor had all my medications at the tip of her finger.

My condition was very altered and confused. I would not have been capable of listing all my meds and their doses. Nor could my husband. The ER doctor ordered lab work which included a Lithium level. In fact my diagnosis was Lithium Toxicity.

This experience has made me a huge fan of electronic records; though uncomfortable with psychiatric records being electronic. But ALL medications should be in electronic records. Drug interactions between psych meds can be very dangerous.

Roy said...

@anon: thanks for the clarification. Patient control of their info should be the standard. That way, you decide who sees what. You are in control. Thus, you won't be concerned about losing privacy because you control the privacy.

That's the ideal. Making it happen remains a work in progress.

@bpladybug: good story.