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