Cue The Black Helicopters

I don't want to cut short any discussion on my last couple involuntary treatment posts, but I wanted to let people know we've got a new Shrink Rap News column up over on Clinical Psychiatry News. My titles over there tend to run on the wordy side, but it's called "RAND Report Signals Threat to Patient Privacy." It's about a recently published think tank report discussing the state of the art of current digital surveillance sources, how they can be analyzed and interpreted and potential applications in national security systems. It's relevant to Shrink Rap because one of the sources they mention----quite transiently and in passing, but it's there----is medical information. And once a person is identified through this Big Data analysis, the report suggests they could be arrested, put under surveillance or taken in for interrogation. Whoa, there's one application of an EMR I never anticipated!

To my knowledge none of this is happening yet, but five years ago I never expected we'd ever hear about anything like PRISM. Go over and read.

Meanwhile, over on KevinMD today there's a similar post by T. J. Derham entitled "How Edward Snowden and PRISM affect health care social media" in which he encourages doctors to still be involved in social media and health care IT systems in spite of PRISM. I'm not sure I'm totally sold on the argument. I want Roy to think about this and put up a Shrink Rap News post pro- or con. Read the KevinMD post here.

I'm going to have to invent new Blogger labels for posts like this now. What should they be? #nsa? #blackchopper? #dontquestionmebro?

HIP HIP HIPAA HOORAY! Where's My Medical Privacy?

And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. 
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Today, I"m ranting about medical privacy (now gone) and electronic medical records over on KevinMD.  The link is HERE.  Did you know that hospitals now send your medical information to the state (at least in our state), whether you want that or not? 

And while you're reading about privacy, there's a terrific article in the Wall Street Journal called Families of Violent Patients: We're Locked out of Care.

Okay, I'm going to make a confession here.  I have no idea what HIPAA is.  I don't know, I don't care.  My practice is small enough that I don't have to give out privacy notices, and I confine my "HIPAA" comments to "I don't release information without your permission."  I also note that I do release information in case of an emergency and that the state has requirements about the reporting of child abuse.  But from my take on it, HIPAA is not about who doesn't get your information, it's a long list of who DOES get your information, like it or not.  When I go to the doctor, I often cross out some of the listed entities, and tell them I don't want my information released.  But no one reads these things so it's just about making me feel like I have some control.  We all like those delusions.

Before HIPAA, doctors were not allowed to release your medical information without your permission.   There was this guy, way back when, named Hippocrates who had something to say on the matter.  Psychiatrists never did talk about your care without your permission, I remember this from before HIPAA.  

Regarding the Wall Street Journal article -- the implication here is that suddenly HIPAA prevents families from getting information about patients against their will.  I sometimes wonder if there is a reason the hospital/doctor/etc aren't plugging harder to talk with the family.  In the case of a violent patient, no doctor wants to see their patient hurt someone or die, and it's hard to imagine that if it were crucial to to share this information, a psychiatrist wouldn't say, "Listen, I can't treat you if you won't let me include your family."  The slant of the article assumes that the patient is always the sick one and that the family is well and harboring nothing but good intentions.  Perhaps the family has been intrusive, or the patient is really adamant.  Do we really want to tell a psychiatrist our private thoughts knowing they will repeat them to our family members whom we don't want to know them?  There are times when a really psychotic person won't allow communication because in the past, the family has insisted he take medication or go to treatment he didn't like, but which helped him anyway, and perhaps that was the right course of action.  But there are also times when families make the situation worse.  I don't think the issue is HIPAA, but I do imagine that part of it is that hospital staff don't have the time to work with patients and their families to help everyone come to a place where families know how to be helpful without being intrusive, and patients can feel more comfortable and respected.  These things take time (sometimes a lot of time) and if you're fighting with insurance companies for an extra day, and spending your time entering data into the computer, when a patient says "No, don't talk to my family,"  the doctor may just say "HIPAA, I can't," without exploring whether that makes sense or if there is a way the patient might allow communication about some aspects of care.  And finally, there is nothing about HIPAA that prevents family members from giving crucial information to a doctor.    

Okay, I've ranted for today.

Why You Should Care About FISA

I know everybody's been concerned about the fiscal cliff lately, but meanwhile something important has slipped under the radar that could be more serious than that for all of us.

Last week both houses of Congress overwhelmingly passed a five year extension to the Foreign Intelligence Surveillance Act (FISA), the law which allows warrantless eavesdropping, wiretapping and monitoring of anyone who may represent a threat to national security. The renewal has been signed into law already by President Obama.

Under this act, government investigators can datamine telephone, email and other online communications pretty much at will. Congress voted down proposed amendments to allow mandatory annual reporting of how often this is done or who this is being done to.

I know this sounds a bit histrionic, but consider this statement from Rand Paul last week:

“Some may ask well, why go to such great lengths to protect records? Isn’t the government just interested in the records of bad people?” Paul said. “Well, to answer this question, you must imagine your Visa statement and imagine what information is on your Visa statement. From your Visa statement, the government may be able to ascertain what magazines you read, whether you drink and how much, whether you gamble and how much, whether you’re a conservative, a liberal, a libertarian, whom do you contribute to, who is your preferred political party, whether you attend a church, a synagogue or a mosque, whether you see a psychiatrist, what type of medication do you take.” (emphasis added)

So this isn't something that, as a mental health professional, you can just shrug off since you're not 'one of the bad guys.'  Particularly now since the public and the government have pressing interests in liberalizing the flow of information between public safety and mental health systems in light of all the recent shootings. The FISA extension grants that authority. If a mental health patient could be deemed a general threat to public safety (read: national security)...well..think about it. Read the full Rand Paul link.

I know everybody is concerned about CPT code changes and impending reimbursement issues, but there's other stuff going on too right now. If you would like to know how your Congressman voted on this issue, you can read the roster here.

[My first post about this topic was in April 2006. It was the seventh of nearly 2000 blog posts we've put up. Seven years later, nothing much has changed.]

Privacy please....

Over on Clinical Psychiatry News, I have a an article up on medical privacy, HIPAA, electronic medical records, routine dental care, compliance and regulation, and yes, fish.  Surf on over if you get a chance.

EHRs & Privacy: Am I The Only One Who Cares About This Stuff?

 

Electronic Health Records are a wonderful thing.  They allow for the easy access of information from one doc to another.  Now when the patient takes the white pill for that bump, I can go in to the records and see what the bump was and what the white pill is.  Once in a great while, it has meaning for their psychiatric care, and it's good for general curiosity, too, and periodically, I may help with the education process if it seems important that the patient should have a greater understanding of their bumps.  Roy likes EHRs and President Obama will pay you tens of thousands of dollars to implement one in just the right way (too many hoops for me).  As a doctor, it's mostly nice.  I still see a lot of people who get portions of their health care in another system and I can't access their labs-- labs I actually need to have to safely monitor how their bodies are tolerating their psych meds, but I'm doing my best.  When I run labs on a patient who gets their primary care outside of our system, I hand them a copy to give to their doctor, hoping that I will spare them a needle stick and spare the 'system' (usually Uncle Sam) the cost of repeating the same blood work.  Who knows if that ever happens.


I've mentioned before that my gripe with this system is that any healthcare professional in the system can access information.  Now everyone I work with, and approximately 10% of my neighbors (wild guess here), and even some of my patients,  have access to this system.  The only thing that stops someone from looking up a friend's medical history is the knowledge that you will get in trouble-- and likely fired-- if you get caught.  But you have to get caught, which means that someone has to look up who accessed the information and track down if it was a legitimate accessing of information.  Now they do it, and people have been fired, and the prohibition is real, but we don't think that in a system of many thousands of people, there isn't a sociopath here or there?


Let me give you an theoretical example: what if a young nurse (he has access) starts dating a pretty young hospital worker (she does not have access to the records; also these people can be old and/or ugly if you'd like....just enjoying my fiction here).  He's curious about her; in fact, he's prone to a bit of pathological jealousy.  He decides to take his chances and look up her records and he notices that someone has run an HIV test on her (it was negative) and she's had a miscarriage a couple of years ago, one she never mentioned to him.  Oh, and psych records aren't in the system (yet, coming soon) but her primary care doc mentioned that she's on Prozac for depression and Seroquel for sleep.  Isn't Seroquel the big guns, maybe she's crazy.  So if he tells her he looked at her records, and she wants to report him, he's toast. But maybe she doesn't want to get him fired, so she eats it.  Also, once he's fired, he's just fired, not dead.  He can then tell whoever he likes, I suppose, especially if he loses his license.  And the saying goes that there are random "flags" that go up to catch wrong-doers, but this is a big system, so I am skeptical.


I've mentioned my concern about this to a few people, especially since the system is about to be overhauled.  I've suggested that each patient have a card or an identifier that the provider should get from the patient to authorize access to the information.  I've asked that this be brought up at planning meetings.  I get looks like I'm from Mars.  Obviously, all health care providers should have access to their patient's records, and in this system, there is no absolute guarantee that your neighbor won't be curious and you don't have the right to not tell the dermatologist that you had a vasectomy three years ago, or to keep your internist from making a note that your antibiotic was started in jail.  Okay, I will say that all of the records I've read (it's been years, that's a lot) are very professional, but still, sometimes the facts are the facts and they aren't all that savory.  I asked if the topic came up at the planning meeting and was told no one else was concerned.  My boss has agreed with me that I watch too much 24.


So I went to schedule a routine screening exam the other day.  I have no reason to be concerned about this, but I am generally uneasy about being in the massive data bank that is the system's records and I avoid it.  I called for the appointment, and the office had been taken over by my hospital system, something new!  I asked if my results would go into the main hospital computer.  Of course they will!  Thank you, I said, I will get my test elsewhere, and I hung up. 


Why doesn't anyone else care about this stuff?

The Secret Lives of Patients

In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing.  The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life. 


Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage.  It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me).  What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy.  He had a secret life.


There's not really much to do about this.  One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website.  Oh, and I am so glad.  


When it comes to hiding medications, or treatments, then perhaps that's different.  Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax?  If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't  prescribe to someone doing such things.  Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his psychiatrist?  We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.


So where is the line?  Is it okay to hide manic behaviors from a psychiatrist---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings!  Is the psychiatrist entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink?  That mom thinks he's getting sick again?  Every fantasy that pops into his head?  Is it okay to withhold your dreams from your psychoanalyst?

I won't go on.  You tell me where the exact line is.  I have no idea.