Does your orthodontist or opthamologist need to know what you tell your psychotherapist in order to provide you with quality care? In the age of electronic medical records, a whole range of health care providers may have access to this information whether you want them to or not.
The issue of how to ensure that psychotherapy notes remain private, even from other doctors, was one that troubled many at the second annual Health Privacy Summit in Washington last week.
“Psychotherapists are often the canaries in the coal mine” when it comes to health privacy, said James Pyles, an attorney who specializes in health law at the firm Powers, Pyles, Sutter and Verville PC.
Here’s what many say is the problem: If a mental health specialist types up his or her notes from a therapy session and puts them into a patient’s electronic medical record, that file can be shared with any doctor the patient sees within their health system. And, because of a loophole in the Health Insurance Portability and Accountability Act, or HIPAA, there’s nothing a patient can do to stop this from happening.
Many mental health professionals, who consider their patients’ privacy and confidentiality to be sacrosanct, find this appalling. But often times, the decision of how they file their patients’ records is not up to them.
Abby Greene is a counselor at a methadone clinic in Long Island, N.Y. Her clinic, which is affiliated with a large psychiartric hospital and health system, recently switched over to electronic medical records and now requires all of its clinicians to enter the notes they take during patient sessions into a computer. Greene said she’s thinking about leaving her job because the ethical dilemmas she’s facing are becoming too much to bear.
She said her notes contain details about criminal activities her patients have engaged in. “When I type information into the file and hit send, I don’t feel good,” Greene said. “I feel like this could harm someone.”
A real-life example of Greene’s fears was offered by an attorney named Julie. After being denied treatment for stomach pains by a new doctor, Julie, who spoke at the summit but withheld her last name, discovered that the doctor had full access to her psychotherapist’s notes. The notes contained detailed information about her regimen of psychiatric medications, her diagnosis of bipolar disorder and the sexual abuse she suffered as a child.
HIPAA expressly prohibits mental health professionals from sharing their psychotherapy notes with anyone if they don’t have their patients’ authorization. However, this only applies if the notes are kept in a separate computer file that isn’t commingled with the patients’ electronic medical record. If they’re not, these detailed narratives are treated just like blood pressure readings or cholesterol levels.
According to Jim Finley at the American Mental Health Counselors Association, behavioral health practitioners have been slow to adopt electronic health records because, unlike with doctors, the federal government didn’t provide them with incentives to adopt. But, in an email, he said his association believes “a substantial number [of practitioners] already currently use electronic records and many more are in the process of converting.”
Finley also writes that most of the members of his association are in small private practices, “but practices are consolidating around the country and we expect more of our members to become affiliated with larger integrated models in the future.”
Some health care practices, especially large, organized ones, integrate the medical files for all of their patients into one electronic record. They say this allows their doctors to provide higher-quality, coordinated care.
But Dr. William Sage, the vice provost for health affairs at the University of Texas at Austin School of Law, says there’s another reason behind the push for IT integration.
“All of this information exists to allow someone to get paid,” he said. “We collect the information we need in order to get paid.”
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Psychotherapy notes are different than progress notes. Progress notes might contain relevant info on symptoms, medications, side effects, mental status exam, diagnosis, and a general treatment plan. Psychotherapy notes, on the other hand, may contain much more personal details, thoughts about how the patient reacts to the therapist, and even the feelings that the patient evokes within the therapist. Example:
Progress note: “Pt continues to have trouble with addiction, missing half of his 12-step meetings, and putting himself and others at risk for negative consequences.”
Psychotherapy note: “Pt using 10 pills of heroin i.v. daily, stealing Social Security checks out of mailboxes from retirees and forging them to pay for this habit. He feels very ashamed of this behavior and wants to stop but his withdrawal symptoms and fear of going into detox again keep him from making a change.”
The rise of EHRs make it even more important now for therapists to self-censor their notes so that this level of detail is not included. You can get paid without putting this down. However, even the basic info in such a limited progress note won’t prevent what happened to Julie. Patients should be able to see what is in their record (with few exceptions) and be able to control who gets to see which records. This requires expanding EHR and HIE technologies to segment data based on what it contains, and to manage granular levels of patient consent. This is doable now, but standards need to be agreed upon and implemented.
Trust in this increasingly electronic health care system is at risk without these safeguards in place. If people cannot trust what happens to their information, they may choose to forgo necessary health care treatment. This is not acceptable.
Privacy requires effort. Each day we take the effort to close the door, or shut the blinds when we need privacy. Similarly we must take some small steps to insure the privacy of Psychotherapy notes. However with new electronic medical records not everyone has the knowledge and skills to implement an effective and convenient strategy for protecting their sensitive digital content.
Our simple solution involves these steps:
Step 1) Create a Folder on your computer with a “trick” name, like “Old Photos” that you’ll use to contain sensitive information.
Step 2) Go to http://www.truecrypt.org/ and download their FREE tool for folder encryption and follow the “Beginners Tutorial” directions.
Step 3) Create your file under your “Old Photos” folder that you will “mount” when necessary to access your encrypted data.
Step 4) Should it ever become necessary to destroy this folder use to avoid having the folder sent to the Recycle Bin. (Not the DEL key on your keypad)
For the best protection and too avoid having to report a lost or stolen PC that contains more than 500 persons information to the government, we highly recommend that you use True Crypt to encrypt your entire hard disk. This process is a bit tricky and not something we would suggest you try on your own.
If you need help, or advice or are looking for an EHR please feel free to contact me. 678-361-4464.
Dr. Daviss I am not picking an arguement with you because it is clear in the body of your post that you are not happy with your suggestion and know that it is a poor band-aid for a problem that needs a much better, strong, respectful solution. I support where you are going with this and so let’s continue, OK?
Although Dr Daviss’s solution is somewhat useful, it still is at best a work around and really waters down the content, the meaning and the Real Reason that one creates medical notes and charts… Notes and charts real main intention if not for Gov’t and Private for Profit Insurance Carriers ill and negative intention blasting their way in here, are for the purpose of helping the doctor keep an accurate record of progress or lack there of, what treatments, meds and therapies have been tried and with what level of success or failure, a record of tests and results as well all for similar reasons… They are for the Doctor first and foremost and obviously for the patient so that the doctor can remember their case and the history over long periods of time, share information with other providers when and where appropriate for the patients best interest in providing that care perhaps via consults and referals, and if and when a patient has need to move out of town or otherwise switch doctors for similar continuity of care.
Only recently has the medical community fallen hook, line and Sinker for this horrible concept of the Singular for one entire lifetime medical record. I complete agree with the warnings of this article and have been attempting to raise similar concerns in my own postings and circles for years. A majority of people lurk or blow off such concerns and then an enlightened and civil liberty aware minority get it and chime in sometimes. I would like to ask the indulgence of the rest of you to state the obvious solutions and to give a couple of other examples of how and why this movement to consolidate and keep one single lifetime record is so horribly fraught with pitfalls and potential horrors of infringement on civil liberties of privacy. First off, we should agree to lable this properly as a potential for the violation of the Civil Liberty of Privacy because that helps frame it more appropriately and gives it the needed clout to be more important and thrump the reasons being proposed from the other side, the Tech Invasion side.
BTW, I am not a Tecno Phob at all, I am my wife’s practice manager at her micro family practice, in NYS and we are just about paperless. We recieve faxes that get converted into PDF’s she almost always works with them in “E” fashion and responds most time in “E”, she is set up and making good use of “E” Rx’ing too, and we recieve her lab results “E” via an secure ONE WAY ONLY connection from Quest Diagnositics. We don’t allow them in, we sent out our labs the usual carrier way with a Demographics page printed out from our wonderful and relatively inexpensive EMR, Amazing Charts, and then they upload and we download with their interface the results which got directly to the patients chart via the correct identifiers and if there’s a misstep we are alerted and asked to properly route the results to the correct chart too… I am the jack of all trades one employee and the keeper of the tiny network and the database and programs we use to be so smooth and paperless…. It can be done and it can be done with patient privacy in mind and that is always one of our has to be met considerations when investigating what products or services we make use of or not. So we were relatively Early Adopters starting in 2004 with a system we did not like and then swapped over to Amazing Charts in Feb of 2006. We have also added Dr. Bert Adams File Assist Pro as an awesome alternative to the pretty good Imported Items section of AC where most of our still comes in paper gets scanned to or the E PDF faxes get filed as well, allowing the doc to have both that item open while also in the patient’s chart, to chart or look at something else as well…. And now we have added his Amazing lables. Dr Bert is the man who runs the Amazing Charts User Board where staff and docs get together to chat about tech and medical issues of all sort. And these programs are connected to AC so if a patient is in AC then the are in those two programs a well… Again one way only… so they must have a chart in AC first… And Dr. Bert offers these items up for FREE to those who can do their own basic computer stuff (basically just setting paths). BUT these charts reside ONLY on OUR Nice Dell Tower workstation and they are NOT opened up to the greater WWW or medical community and there is NO need for this either….
First off any approved EMR is supposed to be able to create a decent CCR, Continuity of Care Record that should be able to be created with a few mouse clicks… And the data is not huge by today’s standards…. So a Mom or Dad could walk into our family practice and get a CCR for themselves and their entire family to walk with for half a dozen people and it probably wouldn’t take up even a Gig worth of space… Pop that on a flash drive and WAM now that family can take the classic summer long cross country trek and have all of their needed family medical records with them for that poor excuse use by the other side “Well what if you visiting your aunt on the other side of the country and get sick or hurt”? Well now there you have it. And if they misplace their flashdrive only 4-6 people are at risk of being privacy violated instead of millions as in so many of the stories that are surfacing and any smart person could have seen coming. No need for national interconnect, Big Brother, Orwellian forever single medical chart.
Now as with any technology especially one that works off of collected and organized data, it is Standardization that comes the ability to share data and information. This is supposed to be one of the most important part of CCHIT and Meaningless Use, and yet it still is many years down the road. But if like CD’s, DVD’s, Blue-Rays and the like, New HD TV and old NTSC, it is standardization that allows what works in NYC work and play equally well in LA on the opposite side of the country. If we put our energies into this problem and need so docs could “E” shoot and share, instance by instance just as we do today with letters, Faxes and the like, create the universal exchange of written typed words, collected values of tests results, PDF’s and Images standardized too, and there you go, no need to combine or risk violating the entire country’s privacy….
BTW, it is not just Psychologists, Psychiatrists and MSW’s that need to separate out and protect their patients’ privacy. In Family Practice we deal with Mental Health and how it many times may or may not interact and be affected by physical health problems too. And we are also in the business of collecting tons of info that is not needed or appropriate for other no need to know providers too…. Is it anybody’s business if you are use birth control or not, what method of birth control no less whether or not you may be considering an abortion or have had one or more of them too???? Is it anybody’s business that your spouse cheated on you for the last couple of years and now you may have a Sexually Transmitted Disease???? And what tests you did or did not have and what those results were? Even your regular medical records could be used positively or against you in so many ways… the Worker’s Comp Insurance Carriers are going to love this so they can raid your medical records (which you have to grant permission to allow access simpy to file a claim) and scour them for any potential reasons that could allow them to write you and your case off, regardless of how honest and real your injury or illness is causally related to something that really did happen on the job and deserves a fair hearing and treatments.
And yet in so many ways who is better set to sort of be the best meeting place, crossroads of all of these interacting and revolving problems and issues than your small personal, intimate family Doctor (not the modern model but a modern return to the older, slower, smaller panel model, but that means one day we need to take on the AMA and the RUC and get equal fees and payments for office visits and “Cognitive” medicine and therapies like Psych as well) who can work the problem from all of the various angles and incoming stuff, treating and dealing with the entire patient, as a singular whole? So we have family practice Primary Care, have lots of both mental health and physical health stuff….
Now what about if theories and medicine change again as much as we today think we have it correct now… As we speak DSM-5 which is political as it is medical and Psychological, Psychiatric…. how many people have “Life Sentence” like Dx’s on their records from the days of Psycho-Dynamics such as Borderline Personality Disorder or kids get mislabled as Oppositional Defiante when perhaps they are the most insightful person in the community and school district, are too intelligent and creative for their less than able to cope with the Gifted with issues kind of child? Should these people be forced to carry these horrible lables that say they are so out of the norms that they can not be trusted or even given a ray of hope? That they may never be able to get well or be “Normal” when perhaps they simply have ADD combined with the ability to cope and express themselves of a tweenager and the insight and brains and spine enough to speak up for themselves and not simply been beaten down in submission of bordom in their crumby school district that wants all high energy and challenging child on “Drugs”??? And if the Diagnosis is incorrect should it follow them for the rest of their life? I know of a good number of people who were given such horrible Dx’s back in the 1970′s and they and their parents had the good sense to walk out of that office never to look back, and allowed that old paper chart to turn to dust in some closet or basement somewhere long ago…. You can’t ever do that, make something actually go away even when appropriate with a forever interconnected national single “E” Health Record. But in an office like ours you can. If you don’t like something and feel our doctor is a Quack then you can simply walk away and never request that we forward your records ever again to anyone for any reason….
If three US Senators, McCain, Obama and Clinton can all have their records violated at the State Dept, supposedly one of the most secure places on the planet should any of us really be gullable enough to believe that this thing can ever really be made nearly safe enough???? One day soon we are going to have a Presidental Election where the women’s choice of birth control or abortion history, or even Menstral Issues will end up being leaked or posted somewhere. And what about their use of the college health services for mild, moderate substance abuse issues or mild stress or depression and the SSRI’s, SNRI’s they were Rx’ed??? With the millions people who are going to be able to get their way into this all to interconnect medical pipeline, techs, front desk people, doctors billing people, nurses & PA’s, and other medical caregivers and support staff, insurance carriers billing people, prior auth people and other employees too, government employees with Medicare and Medcaid who do likewise in their organizations… The amount of people who are going to have terminals with some level of access (and some of them will be savvy and know how to work around and hack into different levels of things too) to this totally interconnected medical records system via the Regional exchanges that then exchange back and forth with one another is HUGE and frightening to say the least….
And the “Brillant” people who are creating the Civil Liberties nightmare believe that their should be a fairly functional and accessable Patient Side as well, so that patients can log in and check out their stuff. So, now a patient that is half mental ill and is not ready to accept their Differential Diagnosis will be able to see that Dx the moment you want to chart it and then get in your face about their Dx of goodness knows what…. And if the patients are going to have ports and portals open and known to them for ALL to know about and make use of, how tight can we make this thing if now basically every 17 year old hacker and wacker with an internet connection has an all too huge and glaring target to try and mess with, that every American and outsiders Too I might add can take a wack at it and see if they can get in there and cause some damage or mess up the works or worse yet, post your medical records on the internet, facebook, U-Tube and all the other social networks out there…. Here I am come and Hack Me!!! Idiots.
Who does this serve, it serves the carriers because now they can read any part of any chart to use it against both patients and providers all. This is the reason it was created and what the “Stakeholders” at the table who were invited and allowed to dominate where the largest corporation who profit on our Nation’s illness and our sick and disabled, and all of us really. No doctor will be able to say that they have not been taken to task and had to do a “Give Back” to the insurance carriers based on their notes and charting… It will become common place and all too regular. And the demands for more detailed and anal notes and charts to justify a level 3 vs and level 4 for example will be insane. Some day soon providers are going to end up spending MORE time charting, defending and supporting their billing and coding that patient care will take even another negative hit, as if there is still any time left to be taken out of the exam or encounter room still. As if we have not squashed down most visits to way too short and worthless, even dangerous at this point already…..
The answer is to remain separate entities with separate systems that have had their software designed to properly share important data and notes… Pulse Ox, BP, ECG’s, X-Rays’ and other imaging devices, labs and allow offices and docs the ability to carefully pick and choose what they want to share and have that data properly routed (never stored, internet packets sent) to the correct providers they need to be shared with. Along with that we could do likewise with flashdrives and discs that patients can walk with like a CCR like file that the other two providers they need to see will have the tests or notes to check out and make part of their record keeping system now. And again in a health, modern most other western nations healthcare system, if everyone had a decent Primary Care doc then they could be the main place that pretty much ALL reports and data (patients choice with the specialists and other providers) notes from the other offices and providers get collected and incorporated… But again that means caring about, supporting and paying much better for, and getting off the backs and out of the offices of, Primary Care Specialties so more graduates go into the Primary Care fields and see it as viable professional and life choice instead of the oath of poverty and completely lost life it has become at the hands of the huge for profit insurance carriers.
And with the use of flashdrives and chips (only get better, smaller, higher in density and cheaper as technology continues to march forward. But at about $15 bucks for 8 gigs worth of space on Memory Chip or Flashdrive that could probably hold a families updates records for years, such is not a huge problem….. families and patients can have almost instance access to their main medical charts to share with others in a pinch almost instantaniously any day or night. They could even email or upload them themselves to a hospital in another city or state if one of their family members is in a car accident far from home at 2 am or something similar….
These are the solutions and alternatives to the over interconnected, way too vulnerable and accessable, single, never to go away electronic medical record system that the “Stakeholders” have created for their own selfish and immoral, unethical, and ever for profit reasons. Tech wants more tech, but not always tech that works well or for those that actually have to make use of it every day. And if you don’t think that the gov’t, the insurance carriers want all of this and are behind most of it (so are billing company, clearing houses, software vendors not owned or run by practioners like Amazing Charts is, BTW NO Financial interest in the company other than that of a dedicated and happy end user of the product) then tell me why the heck do we even need to consider ICD-10, as though #9 is not already a ton of garbage to keep staight already…. It is data for data’s sake and to be used for purposes most of the time that has little if not nothing to do with healthcare and most to do with keeping profits high and costs down…. To treat and restrict docs and patients in a herd like mentality and way…. But with herds there is understood an acceptable Loss ratio and that not all of the cattle are going to make it. Where as in healthcare each patient regardless of stats or evidence based medicine and treatments, are a unique patient population of “ONE” and are supposed to delt with and handled as such….
Adopt and buy good small and cheap, easy to use products like AC or Practice Fusion is another one a lot of our IMP, Ideal Medical Practices friends like too. And keep your outbound ports to the exchanges and the like, turned off CLOSED. To de-centralization, de-centralize our data, small practice to small practice or doctor to doctor…. universal standards for sharing and exchanging, and easy and granual levels of separating out notes and charts via dates of service and individual set of blood work, images and the like….
Thanks for listening gotta run….
Paul