Tag: Behavioral health EMR

Bullying, Privacy, Decency: Where do we stand?

Posted on | by SOS Blog | Leave a Comment on Bullying, Privacy, Decency: Where do we stand?

This morning I saw a friend’s Facebook link to Kathleen Parker’s Washington Post column, With Tyler Clementi’s Death, Let’s Try Friending Decency. On Friday, I had seen an email from the Unitarian Universalist Association, Church of the Larger Fellowship, pointing me to a blog post by the senior minister, Rev. Meg Riley entitled How Can We Create a World Where All Young People Feel Safe? Each of these authors focuses on a different aspect of the tragic death by suicide of an 18-year-old. Parker focuses on the obscene invasion of privacy of this gay young man; Riley focuses on bullying of lesbian/gay/bisexual/transgender (LGBT) young people and on others seen as ‘different’.

If you are unfamiliar with the events, this CBS News report will give you a four-minute overview. To make it short . . . Roommate 1 and his friend decide to publicly out his gay Roommate 2. Roommate 1 sets up webcam in their shared dormitory room, records and then, with the help of friend, publishes online Roommate 2 making out with his male date. Roommate 2 is so humiliated that he announces his suicide on Facebook and jumps to his death from the George Washington bridge. Tyler Clementi’s suicide was the fourth widely reported death by suicide of an LGBT teenager in the past few months.

Roommate 1 and his friend have been charged with invasion of privacy. It is yet to be decided whether they will also be charged with a hate crime.

Both Kathleen Parker and Meg Riley conclude that all of us must assess our own behavior and determine how we can behave differently to preclude such events in the future. Parker’s solution would be accomplished by the community of ‘decent’ folks refusing to tolerate invasions of privacy. . . our own or that of anyone else. Riley’s focus is on bullying of lesbian and gay kids and argues that we must ‘stand on the side of love’ refusing to allow people to be victimized because they are different from most of us in any way.

Reading these articles and viewing the news report on these sad events inevitably makes me think about our current rush to electronic medical records (EMRs) in the world of behavioral health care and chemical dependency treatment. How will be assure the protection of the privacy of the vulnerable populations we treat? Will we put them even more at risk by how we handle the records of their treatment?

I am reminded of a conversation with a customer several years ago. They were in the process of implementing their second try at an EMR. They were working on issues of security and access to data, and were attempting to make decisions about how to handle employees who read the treatment records of clients they have no business viewing. One of their experiences was with a staff person reading the record of a neighbor; another was a family member viewing a cousin’s record.

Of course, these breaches of privacy could almost as easily occur in a paper record world. Pulling a file off a shelf or out of a file drawer is not much harder than calling the record up on the computer. The paper record probably takes a bit more effort and sneaking around than just logging into the EMR that sits on the organization’s network and taking a quick look at what is entered there. Cases in California two years ago emphasized this; medical and nursing staff who had a right to view hospital records did not seem to hesitate at viewing the records of celebrities in their hospital for treatment, whether involved in their care or not. 2009 laws in California increased reporting requirements if inappropriate access of records is discovered. Last year’s HITECH requirements also focus this issue.

It seems to me that the more important issue is how we address the matters of human curiosity and discomfort with others . . . whether celebrities or LGBT clients. How do we create a culture of respect for other people and their right to keep their own information private? Where do we draw the line in our own lives? Do we gossip and tease and reveal secrets shared with us? Or do we empathize and protect and defend those in our lives who are different?

Please share your comments below.

HITECH Act, Psychotherapy Notes and Test Results

Posted on | by SOS Blog | Leave a Comment on HITECH Act, Psychotherapy Notes and Test Results

I am sure some of you remember that the HITECH portion of the stimulus bill (ARRA) included attempts to strengthen the protection of psychotherapy notes in the new Electronic Medical Records (EMRs). In fact, the Secretary of HHS was instructed by Congress to study whether the protections for psychotherapy notes granted by HIPAA should be extended to psychological testing.

HHS is finally gearing up to begin this study and the Substance Abuse Mental Health Services Administration (SAMHSA) has been tasked with organizing and conducting the study.

September 7, 2010
 
 The Substance Abuse Mental Health Services Administration (SAMHSA) is conducting a Confidentiality and Privacy Issues Related to Psychological Testing Data study, in close cooperation with the Office for Civil Rights (OCR) pursuant to section 13424 of the Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act (ARRA) (P.L. 111-5). This study is addressing whether the HIPAA Privacy Rule’s special protections relating to the use and disclosure of psychotherapy notes should also be applied to “test data that is related to direct responses, scores, items, forms, protocols, manuals or other materials that are part of a mental health evaluation.”
 
As part of this study, SAMHSA is hosting public meetings to bring together professionals in the areas of mental health and privacy protection to discuss current practices and the policy implications surrounding this very important issue. The next regional public meeting will be held at the U.S. Department of Health and Human Services Region 5 office in Chicago, Illinois, on October 7, 2010. The details of this meeting, as well as the project staff contact information, are contained in the embedded brochure…. 

 

Some of the issues that will be addressed are included on page two of the brochure.

  • What  activities  and  information  are  considered  the  “test  data”  that  is  part  of  a  mental health evaluation?  What are the relevant distinctions among test materials, raw data, and reports  or  assessments  with  respect  to  the  level  of  protection  currently  afforded  and/or otherwise necessary?
  • Are  there  circumstances  under  which  test  data  should  be  disclosed  to  third  parties?  Should  the  individual’s  authorization  be  required  prior  to  such  a  disclosure?  To  whom should test data be released?
  • How  would  affording  mental  health  test  data  a  higher  level  of  protection  affect  the workflow  in  medical,  behavioral  health,  or  psychological  practices?  Are  there  any additional  implications  with  respect  to  clinical  integration  efforts  and  the  increasing
    availability of mental health services in general health care settings?

Another regional meeting is planned for Los Angeles in November or December. SAMHSA does not indicate whether others will be held. This is certainly an important opportunity to have your voice heard if you are a practitioner whose primary work is psychological testing, if you are a consumer of services who might want or not want raw test data to be shared among treating professionals without your specific authorization, or if you are a potential recipient of such data.

Is the protection of psychotherapy notes and psychological test data an issue for your practice or organization? What guidelines do you currently follow in determining how such data are released? How would new rules affect you?

Please share your comments below.

OpenNotes Project: Where does mental health fit in?

Posted on | by SOS Blog | 2 Comments on OpenNotes Project: Where does mental health fit in?

On Monday of this week, Seth asked me if I had a topic for my current blog. As I had none at hand, he pointed me to last week’s episode of the podcast/NPR show, Science Friday. Seth is a regular subscriber to this series and I listen when I find the time. That effort is always rewarded by fascinating discussions of current science issues. For the science professional, wanna-be-scientist or interested layperson, this show is a ready source of truly valuable information.

On Friday, July 30, 2010 the discussion topic was a medical records project called OpenNotes. With the advent of electronic medical records (EMRs) and patient portals into the medical records system, it is only reasonable to begin to consider the nature of the records that physicians keep on their patients. The OpenNotes project is an attempt to allow some 25,000 patients direct access to what 100 participating primary care physicians write in their notes after seeing them.

The project will study the experiences of both the physicians and patients, the impact on work flow of such note taking/sharing, the possible increase in communications between patient and physician, and the reactions of both sets of participants to their experiences. The details of the study are published in an Annals of Internal Medicine article, Open Notes: Doctors and Patients Signing On.

The Science Friday discussion included concerns about sharing sensitive information with the patient and the ability of the patient to understand and process the information included in the note. It has especially been argued that the mental health patient might be too fragile to be exposed to the psychotherapist’s or the psychiatrist’s true evaluation of their status as stated in the progress note.

On the other hand, Concurrent (Collaborative) Documentation has been touted by some community behavioral health specialists as an essential tool for increasing both quality and efficiency of client interactions while simultaneously increasing client buy-in to the treatment plan. The New York State Office of Mental Health writes:

It has been suggested that Concurrent Collaborative Progress Notes were the ‘way to go’. What about uninterrupted direct face to face contact as the best way to achieve high rates of engagement and retention in our clinics?

Concurrent documentation does not require the clinician to take notes during a session or to detach themselves from the recipient. Rather it is advised that at the end of the session, a brief review of the session takes place and the recipient and clinician collaboratively record the progress note. This process supports the delivery of person centered services and often provides the clinician with important feedback about the recipient’s perspective and information obtained from the session.

The process of creating this record concurrent with the meeting and collaboratively with the client is the epitome of an open record. While the OpenNotes project does not go quite this far, it certainly opens the door in this direction. Since the patient owns the record, it seems only fair that they should have easy access to that record and even participate in its creation.

My background as a Feminist Therapist has long given me a strong leaning in this direction. In the view of Feminist Therapy, the treating professional is a consultant having special expertise who is hired by the client to assist them in solving their “problem”. This is certainly also the case in the medical office. The physician has expertise the patient is seeking in their efforts to treat illness and to live healthier lives. This collaborative relationship is more a meeting of equals working together for the patient’s benefit than a dictation of treatment by an authority-figure intent on successful treatment and risk management.

What do you think about opening progress notes to your patients and consumers of service? How would that change the work done by the provider of services? How do you imagine it would change the experience of the consumer?

Please share your comments below.

Information Overload: TMI

Posted on | by SOS Blog | Leave a Comment on Information Overload: TMI

Almost two months passed between my post last week and the last one before that. The combination of family illnesses followed by vacation and recovery from travel put me in a position of being so far behind in the reading I usually do that I could not possibly catch up. My personal inclination was to duck my head and try to ignore the overwhelming sea of information.

I found myself strongly empathizing with practitioners, administrators, and behavioral health care personnel of all stripes who spend their days trying to provide quality mental health services to their patients…and then spend their nights worrying about what has occurred that day that might get in the way of or assist them in doing their job, but not having the time or the energy to pursue that information. Certainly, the information is readily available on the Internet, but who has time.

There have been numerous discussions of the effects of too much information (TMI) on our functioning. In July, 2008 Nicholas Carr wrote an article in The Atlantic called Is Google Making Us Stupid? This year he has written a book length exposition of that subject called The Shallows: What the Internet is Doing to Our Brain. His thesis is that our brains are literally being changed by the way the Internet is organized. He posits that jumping from one place to another by way of hyperlinks results in shallow pursuit of topics rather than the in-depth exploration of a subject allowed by books. In my brief exploration about his book, I found an extremely articulate review and commentary by Venkatesh Rao who mentioned and hyperlinked to the blog of Jason Kottke, a writer whose name I had heard but had never read. I have demonstrated for you an example of Carr’s thesis. I got distracted from obtaining support for my original thought by the way the Internet presents information and by the ease of pursuing that linked information.

Back to my original thought…here I am adding one more place where there is a bit more information for you to take a look at…or not. You might find this a convenient place to check for information about behavioral health care and its place in the world-at-large, or you might drop in occasionally just to see if there is anything that interests you.

For those of you checking in for something interesting, here are a couple of tidbits.

  1. ONC (Office of the National Coordinator for Health Information Technology) has published a final rule in which it establishes a temporary certification program for electronic health records as required under HITECH. As reported by Healthcare & Technology blog, this rule should allow progress toward approval of certifying organizations for EMR products.
  2. iHealthBeat reports on release of final rules for “Meaningful Use”. Many observers believe that the easing of requirements for the meaningful use of an electronic health record required to receive stimulus funds made available under HITECH will make it easier for eligible providers to receive funds. Other observers believe that even the easing of the standards will not make it simple for stimulus funds to be acquired, even for those who have already purchased and implemented EMRs.

It appears that life gets more complicated all the time, even if we have information. Since I do believe that knowledge is power, I will keep trying to pass some of what I come across on to you. Thanks for reading. Please let us know what you are thinking about. Just enter your comments below.

Patient Consent for Exchange of Information

Posted on | by SOS Blog | Leave a Comment on Patient Consent for Exchange of Information

The HITECH section of the American Recovery and Reinvestment Act (ARRA) added privacy and security requirements that providers of health care services must follow in handling the Protected Health Information (PHI) of those they treat over and above those provided for in HIPAA. HIPAA allowed PHI to be exchanged for treatment and operations without patient consent as along as patients were so notified in the organization’s Statement of Privacy Practices.

HITECH provides for stronger controls. It requires that the provider be able to inform the patient (upon the patient’s request for the information) about all the times that PHI has been released by the organization (disclosures), to whom it was released, and the purpose of the release. This includes release of information for operations and billing. If you send claims to an insurance carrier via a clearinghouse, you would need to be able to document every time a claim was sent and that it went to both the clearinghouse and the insurance company. If you send it to the payer directly on their web site, you would still need to be able to document every time you did that.

HHS has been gathering comments from provider organizations about the burden this will place upon them. How the rules are ultimately written remains to be seen.

At the same time, the HealthIT Policy Committee has been working on a framework for privacy and security of PHI as we move toward EMRs and the electronic exchange of identifiable personal information. An attempt is being made to come up with methods and understandings that will allow a national standard and method of exchanging PHI in spite of different laws and requirements in each of the 50 states. A Privacy and Security white paper series explores these issues.

Part of the current concern is the point in an exchange at which a specific consent should be required from a patient for release of their information. It is believed that patients feel fairly secure when provider #1 releases information to provider #2 whether the provider is a lab or another physician. Trying to determine the point at which comfort in an exchange is lost and the requirement of consent is triggered is part of the challenge. For example, if provider #1 has consent to send information to provider #2 but the only method of doing so is through a third party (like a clearinghouse or directory), does additional consent need to be obtained for that transaction? What kind of situation must exist to trigger a patient’s right to “opt out” of the electronic transaction.

These are important issues that pertain to information electronically exchanged for billing and operations as well as for treatment. Avoiding the use of an EMR will not shield you from addressing these issues if you send claims electronically. . . even at a payer’s web site. 

What do you think about protecting the PHI of the consumer of services?  What are you doing to assure that you meet the requirements of the law? Please share your thoughts and comments below.