Traditionally, most hospitals have separated out the psychiatric record from a patient’s medical record. This was done historically because of the stigma and discrimination associated with psychiatric concerns — and the serious lack of training in medical school for physicians to understand such information in proper context.
As hospitals move to electronic records, the default behavior has been to simply keep things as they are — so no more processes than necessary have to change at the same time. This means keeping the psychiatric information in the electronic record segregated from a patient’s medical information.
But in an intriguing new study just published — on a very small cohort — researchers found that where hospitals allowed any properly authorized medical staffer to access the patient’s psychiatric information in the electronic health record (EHR), hospital readmissions went down.
Perhaps it’s time to re-evaluate whether opening up the sharing of such information among all doctors on a patient’s treatment team might actually be a good thing.
To get the data, the researchers surveyed 18 hospitals on the 2007 U.S. News and World Report list of the “Best Hospitals in the United States.”
“Of that group, eight hospitals (44 percent) kept most or all of their inpatient psychiatric records electronically, and five (28 percent) let non-psychiatrist physicians see mental health records, including psychiatric admission notes, discharge summaries, notes from the emergency department, and consultation notes.”
Just four hospitals did both. Among this latter group, however, readmission rates for psychiatric patients were substantially lower than at the others on the list. Here’s what they found:
Top teaching hospitals that provided non-psychiatrists with electronic access to inpatient psychiatric records had up to 39% lower rates of readmissions within 7, 14, and 30 days of initial discharge than comparable institutions that did not include inpatient psychiatric notes in their EHRs. Full access also cut 7-day readmission rates by as much as to 27% when compared to hospitals that did not let primary care and emergency physicians see psychiatric records in the EHR
I only have one concern — that non-psychiatrist physicians treat the psychiatric information with the same care they would as if it were their own information. Sometimes doctors are a little too loose with a patient’s medical information when talking to other docs — especially in public places where many others may hear (like an elevator).
I’m also concerned that stigma, discrimination, prejudice and misunderstanding are still fairly rampant among some physicians — especially in certain specialties. Without proper education and training, I worry that some doctors may misuse or inappropriately share information gleaned from a patient’s psychiatric record. Proper education and training could readily solve this concern, however.
Patients, too, ultimately benefit from such increased sharing, as this study — if confirmed by others — demonstrates. If patients are afraid of this development, I usually find information is the best remedy — showing patients exactly what is and isn’t in their medical and psychiatric charts. Patients, of course, have a right to view their medical and psychiatric records in their entirety. In most instances, once a patient sees how little is actually in their psychiatric or mental treatment progress notes (if it’s being properly maintained), they’re usually satisfied.
I’m a big believer in the benefits of transparency and open communication. If giving doctors access to all relevant data of a patient — including their psychiatric history — can help patients receive better care, why not do it?
Read the full article: Sharing Psychiatry EHR Data Cuts Readmission Rates
9 comments
I wouldn’t see my psychiatrist if his record was part of a general medical record for other doctors to access. I work in healthcare and I have heard comments, and I don’t want to have to worry that my concerns will not be taken seriously when I see another physican. Patients should always be able to opt out of a plan like that, if not, then many won’t see a psychiatrst (or therapist). I know I wouldn’t.
My primary care doctor had a note in my file stating I had a chronic mental health disorder. Whenever I would seek treatment, the doctor would ask me how work was going. He seemed to attribute whatever symptoms I described as attributable to being mentally ill.
I changed doctors. I told the next doctor I was receiving treatment for my mental disorder. I also asked the primary care doctor if I needed a note from my psychologist to receive treatment for asthma as a non-related mental health issue? The primary care doctor laughed. I told him I did not see the humor.
Then I asked the primary care doctor straight out if he could put aside the note in my file and actually treat me for the issue presented. The primary care doctor took the mental health note out of the file.
For the first time in years I did not have to try to convince my primary care doctor that mentally ill people can have non-related physical ailments too.
I really don’t want psychiatric information combined in my electronic record. I’m betting hospital readmits went down because the “this person is just crazy, get rid of them and dont admit” attitude was prevalent.
As a healthcare professional myself I am sad to say that attitude is the one displayed by about 95 percent of my coworkers. Why would psychiatric info have any influence on a readmit for a physical issue? I am not sure if psychiatric readmits or admits for physical issues were meant here. In the ER we have people with a ruptured appendix or advanced pneumonia who also happen to have bipolar or schizophrenia. The record clearly shows where they were sent home (or even sent to the PSYCH HOSPITAL) on earlier visits complaining of the same issue …but the diagnosis was “factitious” (ER speak for GET THIS PERSON OUT OF MY ER NOW). They have now reached the point where they are so ill that only emergent treatment can help them.
I seek my psychiatric care outside of the provider network where I am employed. I don’t want the details of my bipolar 2 disorder in the record my coworkers see when I get care for non psychiatric disorders.
Sorry, clueless, absolutely clueless! I can’t tell you how many times a non mental health provider used mental health records irresponsibly, even with the best of intent.
Here’s an example for readers to decide if I am off base, or hit the bulls eye in this point: had a patient who was going through marital difficulties and was on a psychotropic; the PCP INSISTED on getting all of the records from my office to clarify the psychiatric care, and then one day in follow up with the patient, asked the patient why they were involved in marital infidelities.
Guess who caught fecal contents in follow up from that visit? Not the PCP, but, ME! And the patient was not mad at ME, but the fact that I had to release all the records solely because the PCP insisted to have all the records, even the progress notes. The patient was more forgiving at the end of the visit with me, but I didn’t forget it.
Nor have I ever released all records when someone who is a health care professional requests ALL records in a release since then. All PCPs need is the diagnosis, meds, and pertinent medical info from the psychiatric intervention.
face it folks, confidentiality is the hallmark of what defines mental health care. Because at the end of the day, if a patient tells us something that is just between him/her and me, NO ONE else needs to know.
Really surprised you take this position in your post, Dr Grohol. Might want to step back and reappraise where you are near the cliff, dude!
I would welcome my psychiatric record being integrated with my main records. I am a whole person and need to be treated as such. we have so many different data files – the GP has one, each of our 2 local acute hospitals have their own,and the psychiatric one is on another system. None of these are compatible with each other. Letters fly back and forward and i can have died before the pigeon mail reaches the GP after a crisis. i have produced a document of my own, an advanced statement of my wishes and had to send it separately for each record but the acute hospitals can’t accommodate it! Not very helpful!
The problem with the study is that it does not get a why those patients were not readmitted. Perhaps now all their symptoms get chalked up to mental illness and thus ignored, where as people without mental illness get treated.
i wish that it was like Diana said that disclosing psychiatric history led to patients being treated as whole persons, unfortunately there are too many examples i know of where that’s not the case.
Several years ago, i was in the psych unit of a hospital being treated for major depression. While there i developed a urological problem but the urologists at that hospital didn’t see patients in the psych unit, they saw patients in every other unit however. So much for being a whole person.
Once i was stable for a long time i became a health care professional myself (not mental health care) and worked in a couple of hospitals. The things i have heard from some physicians, nurses, and even some mental health care professionals have convinced me that it’s often a bad idea to disclose a psych history.
i tend to avoid seeing a PCP because i don’t want them to know the psych meds i take. i don’t want to deal with the assumptions they may make, and god forbid they ever learn i was in a psych unit many years ago.
Just google “Cassandra Sampson and Beth israel” to see how risky it is to disclose a psych history at an ER. She went to the ER for a migraine and ended up being forcibly stripped by male guards once they learned she had a psych history. Patients who had a psych history were all required to disrobe even if they weren’t violent. I guess the sociopaths who visit an ER are safe from that since they don’t tend to see a psychiatrist. Punishing patients for seeing a psychiatrist. Fabulous.
Since commenters are noting hassles of being identified with a psychiatric history while in inpatient care, here’s a gem I had while working in residency that showed to me how ridiculous ER staff were back in the 1990s:
Got called after 2AM on Saturday night to see a man who came in with abdominal pain, and I was called because he was on Lithium. Not that he had any complaints re psychiatric matters, I had to see him because he was on Lithium.
Labs came back noting he was taking the medication properly, except one little abnormality that did not account for Li use: he had a white count of 25,000 and showing what is called a Left Shift, meaning his marrow was producing immature WBCs to fight off an infection. “The high WBC count is due to his Li use” said the attending who called me, yet no one explained why he had abdominal pain and why that was turfed to me to figure out.
Well, I go to see this man, who was in obvious discomfort while talking, so after about 5 minutes, I asked him to lie down and did a cursory abdo exam, and when I went to check for rebound tenderness by pushing down on his abdomen and let go, this man let out a scream of pain that had 2 security guards in my room in about 5 seconds.
I asked the ER staff to see him again, to find out NO ONE did an exam on this guy after drawing his labs, and they quickly realized he had an acute abdominal problem and had surgery staff see him, who promptly admitted him for an emergency procedure.
The next morning around lunch, I had a surgeon page me and meet in the cafeteria to tell me what a good job I did in assessing the man for an abdominal problem, in this case appendicitis in which the appendix burst when they opened him up.
The next thing I was told I will never forget: the surgeon spoke to the ER attending after the surgery to ask why this patient was not referred earlier in the evening, and get ready for this answer, “well, we thought he had psychiatric issues and felt psychiatry would find out what was somatic versus hypochondriac issues, and I guess it was good the resident picked up on the abdomen issue, because we were ready to discharge him.”
The surgeon told me I saved this man’s life, because if I just signed off there were no psych matters, his appendix would have burst at home, or more likely on the street as he came in by taxi.
Hey any medical colleagues out there who pay attention to the standards of care to this day: you have to rule out somatic factors to symptoms complained that could have somatic causes. Sending psych patients to psychiatrists to diagnose thyroid disorders, hypoglycemia, atrial fibrillation, adrenal gland disorders, brain tumors, and some other things I HAVE CAUGHT in my psychiatric office do not shine positive lights on turfing care because the patient has a psych history.
And State and Federal governments want to improve mental health care treatments after Newtown. Yeah, right, just throwing money at a problem will get it solved.
How much to pay for pervasive bias and discrimination these days, eh!?
Putting psychiatric records together in a medical record is reckless and would lead to increased stigma and shunning of patients- less care not better care.
There is more stigma now than ever, and the risk associated with seeing a psychiatrist needs to be evaluated by anyone who decides to see a psychiatrist or psychologist.
HIPAA protections are scheduled to be lessened for psychiatric patients, the NICS database will have a registry, many of whom will never harm anyone.
There is a public perception that mental illness equates to dangerousness when in fact patients are more like to be victims of violence.
In general with electronic records and public perception, patients need to seriously weight the benefit against the risks.
Psychiatric patients are stigmatized and scapegoated enough, without the added burdens of being denied the basic dignity to be able to share confidentially with a trained professional.
I suspect people are going to refrain from seeking treatment, as they should.
A label of untrustworthy and dangerous, when none exists, will keep them from housing, employment, relationships.
It is a sad state of affairs.