A story last week caught my eye about a patient, Julie, who was surprised to discover that her psychotherapy notes became a part of her electronic health record at the hospital system that administered her care — Partners in Boston.
She found out that any doctor within the Partners system could access her record — including her sensitive psychotherapy notes — with no reason whatsoever. And she only discovered this privacy issue because her new internist initially refused to prescribe her needed medication because of “concern” about her psychiatric history — a history he had access to and read without the patient’s prior knowledge.
There’s a couple of problems here. But it’s a teaching moment for others implementing system-wide electronic health records. Psychotherapy notes enjoy special status in the health care community, and that special status should continue even in the age of electronic access.
There are a few issues this case illustrates.
Nobody in the article quoted seemed to recognize the differentiation between psychotherapy notes and progress notes. Psychotherapy notes enjoy specific HIPAA protections, whereas progress notes do not.
Progress notes in a hospital setting generally follow a standardized format, such as SOAP — Subjective, Objective, Assessment, and Plan. This method was developed in the medical setting to standardize entries in the patient file, as follows:
- Subjective: “Patient complained of …” (how’s the patient feeling this week, in general terms?)
- Objective: Blood pressure, lab results, results of physical examination (in psychotherapy, the only objective measures that may be put here from session to session are the results of a symptom inventory scale or the like)
- Assessment: Clinical diagnosis of symptoms (how’s the patient doing this week?)
- Plan: Prescriptions, treatments recommended, etc. (how’s the patient’s progress with respect to their overall treatment plan?)
If a psychiatrist or therapist is using the SOAP format in an electronic medical record, there usually is little detailed information given in such notes. Well-trained mental health professionals recognize patients’ privacy needs, and keep the details of each psychotherapy sessions out of SOAP notes (especially details that aren’t pertinent to others).
Psychotherapy notes, on the other hand, are usually segregated from the official patient record. In many clinics and hospitals, if a professional keeps psychotherapy notes (not all do), they can be kept in the professional’s possession, or in a separate file in their office. Psychotherapy notes contain more detailed and personal information about each patient’s session. This helps a therapist keep track of a patient’s progress more easily, and th e details of each patient, each week they are seen.
If a doctor or therapist isn’t properly trained on these differences, they may be confusing the two and actually writing psychotherapy notes into the patient’s medical record.
If an electronic health record (EHR) is offered within a hospital system, the EHR is required to separate out psychotherapy notes from the regular medical record. It’s not clear whether access should be restricted to such notes to other medical personnel, but many privacy advocates believe that is HIPAA’s intent. There is little reason an untrained internist should be allowed to access psychotherapy notes — they have neither the experience, licensure nor training to properly understand such notes.
Instead, what is more likely to happen is what apparently happened in the case of Julie and Mass. General:
She wanted him to manage her medications for bipolar disorder while she found a new therapist. He gave her a cursory exam and encouraged her to see a psychiatrist, she said in an interview. The doctor told her he had read the notes and was not comfortable prescribing her medications, although he eventually agreed to do so.
The article doesn’t make clear whether he read simply the patient’s psychiatric progress notes or the more detailed and should-be-protected psychotherapy notes.
At Partners, apparently in an effort to help transparency for their medical staff (but not telling their patients), “patients can ask that notes be restricted, but the organization evaluates the requests on a case-by-case basis.” Huh? So what you tell your psychotherapist in confidence, and then transmitted by your unwitting mental health professional into the medical record, becomes fodder for any doc who happens to have access to the Partner’s system?
But Dr. Thomas Lee, head of Partners’s physician network, said segregating psychiatrists’ notes fosters that stigma. “Schizophrenia and Parkinson’s disease are both biochemical disorders of the brain. Why is one considered mental health and the other medical?”
Lee, of course, is not a psychologist or psychiatrist, so he has no special understanding of mental health concerns (he’s a cardiologist). I’m sorry… I respect my cardiologist’s opinion when it comes to concerns about my heart. I have less respect for his understanding of the complex nature of mental disorders and how society perceives them, because he makes a blatantly false statement about schizophrenia.
Schizophrenia is not some pure “biochemical disorder of the brain.” We now know through decades’ worth of research that it’s an incredibly complex disorder, with no specific genome identified, and none forthcoming on the horizon. It’s no more a pure “biochemical” disease than obesity is.
To suggest, “Hey, docs don’t discriminate or have any prejudice against these disorders because they’re all just biochemical” is either incredibly naive, or just an overly simplistic argument to make.
Partners’ privacy protections for psychiatric notes appear to be set to the wrong default. By default, psychotherapy notes should be off-limits to other medical professionals. If they need to access them, the EHR should have an option that allows them to request access, which is then reviewed and approved (or not) by the patient’s treating therapist. Or how about this? The request is reviewed and approved by the patient first.
It is, after all, their life.
Read the full article: As records go online, clash over mental care privacy
15 comments
This is exactly why I do not sign medical record releases at mental health offices.
To answer the question that opens this post: NO!
Confidentiality is the hallmark of good mental health care. Period. You open that alliance to third parties who do not understand or respect that principle, all can be lost.
By the way, meaning to ask, why all these added screens to get to the comment section? Quite annoying!
Yes, I agree, the simple answer is that psychotherapy notes should not be an unprotected component of the electronic health record. If they are to be incorporate in any manner in an EHR, they should be protected and released only by consent of the patient. Just as is done with a paper record.
A lot of times, developers and companies do things just because they can — because the technology makes it possible.
They don’t often enough stop to ask, “Just because we can this thing, should we? There’s a reason the current system exists, and we’re bypassing that system.”
John
The same thing that happened to this woman happened to me — at Mayo Clinic, a leader in just about everything, including electronic records. Heck, they even have an iPhone app where you can order prescription refills, see your upcoming appointments, discover good places in the area for lunch, and about 600 other things.
However.
I did NOT expect a non-MD in the endocrinology department (a dietitian, to be specific) to be able to see my psychotherapist’s notes and ask me about them. I was so taken aback that I didn’t ask why it was relevant to her, and I wish I had. But I assure you that I brought it up to my therapist at our next appointment and had her put a block on her notes.
Personally, I think I should be the one who decides who gets to see that kind of sensitive information. At the very least, it does need to be separated out from the rest of the record and password protected.
Mayo now lets patients access “clinical summaries,” which the MDs write following appointments. They’re supposed to involve the problem the patient came in with, how it was addressed, and ideas for how to proceed from there. I’ve found, however, that they also sometimes include the MD’s perceptions of the patient — which are sometimes less than flattering. I would rather not know. I don’t really want to see my records at all, unless there’s some pressing reason for me to double-check their accuracy. I think the “just because we can” mindset John addressed above is one that really needs to be reconsidered in the case of EHRs…
Candy
I am a physician who receives mental health care at Walter Reed–and so my supervisors, coworkers, and those I supervised all have access to my record. When comments from my supervisors made it clear someone had been accessing the notes from my therapist–including a detailed initial evaluation–I filed a HIPAA complaint, which the hospital refused to investigate. After that my doctor’s notes became very brief and vague but it has taken a toll on the therapeutic alliance. Our system tracks everyone who accesses mental health notes–but out of fear of identifying a service chief violating HIPAA the military chose not to audit. Military health care at it’s best.
What about the information from medical PCP to our charts? Does the referral note with all concerns and medications and illnesses? What of our having access to medical information? Does the same concern hold? Why and why not?Also, about when I see a client in behavioral health and the client may need to see PCP or psychiatrist for medication on same day, why only one of us can bill when in fact both had to do their part in providing service to this client. Is the new code with the add-ons allow for both with good reason to bill? If in a medical setting this is very important consideration and working together. Your thoughts?
Does a doctor have access to psychotherapy notes (or even SOAP notes) if my therapist was in a small practice not related to any larger health system? I would feel uncomfortable even having my doctor access the therapy progress notes, as I made comments about the doctor and was experiencing a lot of health anxiety. Please let me know. Thank you for the article.
I am in the same situation. My psychiatrist told me my records are not accessible to anyone outside his office.
My question is what if my doctor becomes part of a larger health care system. Would my notes then be available to anyone in that system besides the janitors at any time without my permission? What happened to Hippa laws? Those notes were supposed to require me to sign a waiver before they were shared with anyone.
I no longer see a psychologist because of EHR and I no longer freely share my thoughts and feelings with my psychiatrist now, either. There is no such thing as privacy rights for patients anymore.
I would not see a mental health professional who used an electronic medical record. It’s too risky. There are data security breaches all the time. Just google it, and you can read countless examples. They’re not secure.
The government requires mental health professionals to make their records electronic now, but I don’t know if that includes psychotherapy notes. They are given smaller reimbursement from Medicare if they don’t cooperate. I asked my psychiatrist to keep my medication and psychotherapy notes on paper and he said no. I am going to file a complaint with Hippa, but I don’t know if it will help. I would at least like the psychotherapy notes to be on paper.
I just read that 90% of doctors and hospitals last year exposed patients’ data or had it stolen on cnn.com.
Thank you for this interesting article. This is obviously a complex issue – especially in large multi-disciplinary and hospital systems. Thank you for pointing out the pitfalls that many of us might be unaware of.
I would like to point out, though, that the disconnect between primary care provider and psychiatrist, fragmentation of care, and the separation or siloism between primary care and psychiatry are partly responsible for increased morbidity and mortality of patients with psychiatric illnesses. So I think it would be most helpful to come up with systems of integration where possible, data sets that in fact *should* be shared, and a means for communication and need-to-know access in this electronic age.
As a family physician who works in a clinic that sees mostly low-income folks in an urban setting, I feel like I spend at least half of my time working with patients on issues that would be considered (or related to) mental health issues. With such high levels of violence/trauma, incarceration, etc. among our population and in our area, we can’t truly provide primary care without addressing these realities. We specifically brought in mental health providers in an effort to truly support patients in an interdisciplinary, holistic manner. We case conference, and the mental health providers access and view our progress notes (although “they have neither the experience, licensure nor training to properly understand such notes”). What they don’t understand, they ask. We do separate the psychotherapy notes (to keep the special HIPAA protection), but primary care docs can ask for and review the mental health notes any time. And what we don’t understand, we ask. In a primary care setting that is integrating mental health, I see no reason for doing things any other way. I believe it improves the level of care the patient receives and treats them as what they are: a whole person. It also leads to providers on both sides that are better-informed and better-equipped to care for their patients, many of whom have mental as well as physical diagnoses.
I definitely would not see a family doc who was able to access my mental health records, as Family Doc is able to do. I choose not to share psychiatric information with my internist, my dermatologist, or any other doctors. What I share with my psychiatrist is between he and I.
This is exactly what just happened to me. A GP saw my psychotherapy notes as part of an electronic record in a larger system and denied me a course of treatment based on them, as well as making them part of my general medical records. In my state, disclosure of general medical records are not very strictly governed, so basically the contents of my notes are now “on the loose” in my general records. What can I do?
I know that this is an old article, but I just found it and really appreciated it.
I am going through something similar right now. I was in hospital in British Columbia, Canada for an emergency abdominal surgery, which should have had nothing to do with psychotherapy. While I was in recovery, they kept putting severely mentally ill patients in with me (ie one had delusions and screamed all night, another was a drug addict with schizophrenia), and I casually asked the nurse why that was. She looked puzzled and told me that “we always put you people together”.
A few weeks later I was at an outpatient ostomy clinic, and the nurse left my file on the desk. There in large, black print was the phrase “Patient has mental health issues”. When I flipped it over, there was an entire history of psychiatric care in my file.
The thing is, I have never been under psychiatric care and have never been diagnosed with any mental illness. It turns out that while I was recovering from anasthetic, an RN with no special training took it upon himself to do “a full psych eval” and put it in my medical records!
The hospital says that there is no way it can be removed now, and for at least the next ten years ever healthcare professional that I visit will see this false information. Patients really need to have the right to protect their own medical information!
I’m in an uncomfortable situation because of this. 1) my psychiatrist is medication management only. She isn’t my therapist. 2) she ask me the same basic questions every time I come in. Thoughts of hurting yourself or others are you hearing voices or having hallucinations. The answers have consistently been “noâ€. Prior to seeing her my diagnoses had been pretty basic, but after seeing her I recently learned through those records that she had greatly expanded it Roughly 6 8 months ago, I started seeing a medical doctor in her network. BIG mistake. Every reaction or concern I had about my treatment, the doctor related to this greatly expanded diagnosis that was created from our 5-10 minute psychiatric visit. Example: I question the prolonged use of Prednisone the internist had me on and the issues like greatly increased blood sugar levels to the point of being borderline diabetic and blood pressure rising with each visit and a host of other things, and this doctor started talking about my “trust issues! She in turn passed info on to the rheumatologist in their network. The nurse was talking to me like I was a child and saying things like, “I’m going to touch your arm now†and “you did really goodâ€. The rheumatologist started telling me stuff about mentally dealing with the things that come with getting older, and when she prescribed a sulpha drug that i am highly allergic to and which is in my chart, she pretended to others in the network that I blew up, when i didn’t bring it up to her.. I found out at the pharmacy, left a written message on the online portal not with her but with my internist, and talked to her only one only time 3 weeks later when she phone for a one minute check in.
Anyway, these notes follow you an effect your relationship.with every doctor in that system and others in the EHR system. I had diagnosis I never even knew I had in my mental health record, and others knew about it before I had ever heard about it and this is from a psychiatrist who only took over medication management from a doctor who left town and barely speaks to me, but she has heard things from 2 estranged family members I recently learned, and she based her diagnosis there and passed it on. I just am having a hard time feeling like she has my best interest at heart, and I have only a few other choices, but I do t want electronic health records.