For Prof Howard: Discussion Post & 2 replies

profilelewirt
confidentiality_and_electronic_medical_records.pdf

Confidentiality and Electronic Medical Records for Behavioral Health Records: The Experience of Pediatric Psychologists at Four

Children’s Hospitals

Beverly H. Smolyansky and Lori J. Stark Cincinnati Children’s Hospital Medical Center,

Cincinnati, Ohio

Jennifer Shroff Pendley A. I. duPont Hospital for Children/Nemours

Children’s Clinic, Wilmington, Delaware

Paul M. Robins The Children’s Hospital of Philadelphia,

Philadelphia, Pennsylvania

Karin Price Texas Children’s Hospital, Houston, Texas

With the advent of electronic medical records (EMR), pediatric psychologists working in medical centers must address how confidentiality of behavioral health records will be defined and integrated into the larger EMR. Pediatric psychologists at four children’s hospitals share their decision-making and outcomes as their home institutions transi- tioned to an EMR. All four formed committees of relevant stakeholders and legal advisors to define the legal and ethical issues and all four had mechanisms to commu- nicate provider concerns to and share committee opinions with providers. Two of the four required patients to give consent for behavioral health records to be integrated into the larger EMR, one integrated behavioral health records completely without required specific consent, and the fourth differentiated integration based on the type of service provided, with those focused primarily on physical health concerns fully integrated and those focused on behavioral health limited access to only behavioral health providers. The EMR at each institution allowed psychologists discretion to keep individual notes or portions of notes at a heightened level of confidentiality even when integrated. At all four institutions, medical colleagues valued having the behavioral health records fully integrated within the EMR, both the psychologists and their medical colleagues appreciate the improved communication with an integrated EMR (whether by consent or default), and the broader confidentiality protections of each institution has ensured that records are not accessed by those not involved in a patient’s care. Most important, families appear to appreciate the benefits of an integrated EMR.

Keywords: electronic medical record, behavioral health record, confidentiality

Psychologists are obligated to maintain pri- vacy and confidentiality of behavioral health records based on the Ethical Principles of Psy-

chologists and Code of Conduct (American Psychological Association, 2010). They are therefore required to take reasonable steps to

Beverly H. Smolyansky, Division of Behavioral Med- icine and Clinical Psychology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincin- nati, Ohio; Lori J. Stark, Division of Behavioral Medi- cine and Clinical Psychology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and Uni- versity of Cincinnati College of Medicine; Jennifer Shroff Pendley, Division of Pediatric Behavioral Health, Department of Pediatrics Nemours/Alfred I. duPont Hospital for Children, Jefferson Medical College, Wil- mington, Delaware; Paul M. Robins, Department of

Child and Adolescent Psychiatry and Behavioral Sci- ences, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Karin Price, Section of Psy- chology, Department of Pediatrics, Texas Children’s Hos- pital, Baylor College of Medicine, Houston, Texas.

Correspondence concerning this article should be ad- dressed to Lori J. Stark, PhD, Division of Behavioral Medicine and Clinical Psychology, MLC 3015, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229. E-mail: [email protected]

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

Clinical Practice in Pediatric Psychology © 2013 American Psychological Association 2013, Vol. 1, No. 1, 18–27 2169-4826/13/$12.00 DOI: 10.1037/cpp0000009

18

secure patient data and share information only with persons directly involved in the care of a child. In the age of paper records, this was a relatively simple task. Typically, records were maintained by the individual psychologists in their private offices, or, if practicing within a larger hospital system, records were often kept separate from the general medical record by being kept in locked filing cabinets in the be- havioral health division or department. Sharing information only happened with direct written consent from the patient or guardians. Privacy was easy, but in a larger hospital system where pediatric psychologists are involved in the care of medical patients, this privacy came at the cost of collaborative care and patient safety. For example, emergency room physicians would typically have no record that a child was in therapy. Pediatric psychologists based in multi- disciplinary clinics had to complete redundant records, in the form of reports and letters to the team, in order to share information. With the advent of electronic medical records (EMRs), many subspecialties moved to their use, stream- lining documentation and billing. However, the first electronic record systems were most often implemented in isolated pockets of different subspeciality practices. Thus, early electronic record systems were unable to communicate with one another and resulted in isolated islands of data within hospitals.

In April of 2003, the Health Insurance Por- tability and Accountability Act (1996; HIPAA) went into effect. This law sets criteria for pro- viders to protect medical information, increases access of patients to these records, and man- dates education of patients about their rights. HIPAA did not replace state laws or the need for consent, but it did put regulations in place for behavioral health and other subspecialties to consistently protect confidentiality of medical records and patient data. HIPAA also attempted to define “psychotherapy notes” as notes “doc- umenting or analyzing the contents of conver- sations during a private counseling session.” The definition expressly excludes medication prescriptions and monitoring, counseling ses- sion start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date (HIPAA, 2003 sec. 164.501). Psychotherapy

notes, by design were notes that were never meant to be read, would never be sent forward for billing purposes, and would require a sepa- rate release of information to access them; un- der HIPAA, they were required to be kept sep- arate from the medical record.

The rapid expansion of the use of electronic medical records in hospitals followed a clear timeline. In 2004, the federal government pol- icy makers set a rather lofty, long-term goal that electronic medical records should be in place for all providers by 2014 (Hing & Hsiao, 2010). By 2007, it was estimated that 34.8% of physi- cians had instituted an electronic medical record system (Hing & Hsiao, 2010). In 2009, the federal government offered stimulus money to assist hospitals in the development and adoption of health information technology. Although many hospitals, such as Cincinnati Children’s Hospital Medical Center, had already decided to make the move to an electronic medical record, this money added an additional incentive to accelerate this move. With this acceleration of electronic medical records within hospital sys- tems, pediatric psychologists have had to make important decisions that balance confidentiality and patient safety as well as state and federal laws about confidentiality.

The purpose of this article is to highlight the path taken by pediatric psychologists in four children’s Hospitals (Cincinnati Children’s Medical Center, A. I. duPont Hospital for Chil- dren, Children’s Hospital of Philadelphia, and Texas Children’s Hospital), to understand and balance these issues as an EMR was introduced. Of note, because all four hospitals chose Epic as the EMR system, capabilities across all hospi- tals were the same.

Cincinnati Children’s Hospital Medical Center (CCHMC)

The Division of Behavioral Medicine and Clinical Psychology (BMCP) is a freestanding pediatric psychology service within CCHMC. The majority of practicing pediatric psycholo- gists are housed within the division, with the major exception being psychologists housed within the Division of Developmental and Be- havioral Pediatrics (DDBP). Psychology pro- vides care on an outpatient referral model, em- bedded within medical teams (e.g., headache clinic with neurology, pain clinic with anesthe-

19BEHAVIORAL HEALTH RECORDS AND EMR

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

siology), an inpatient consultation liaison ser- vice, and an outpatient child clinical service through four CCHMC satellite locations. Epic was introduced at CCHMC in March 2007 and gradually implemented across three to five di- visions a year. BMCP was rolled out in October 2009. Prior to Epic, BMCP had been using a locally developed electronic system that al- lowed psychologists within the division to ac- cess each other’s patient records electronically but that did not have electronic signature capa- bilities. Therefore, all notes were printed and stored in paper charts that were kept within the division. Thus, we were comfortable with keep- ing all behavioral health records separate from the main medical record.

In anticipation of moving to an enterprise- wide EMR in which records could be accessed by other professionals within the institution, CCHMC convened a mental health task force about a year prior to going live to begin discus- sions around sharing of behavioral health infor- mation. This group consisted of a representative from BMCP, psychiatry, DDBP, social work, health information management (HIM), legal counsel, the Chief Medical Information Officer, and an Epic representative. Topics discussed included (among other things) documentation of abuse, use of sensitive notes designations, releasing diagnoses on “After Visit Summary” forms, public viewing of diagnoses and chief complaints, and level of access needed for var- ious staff positions. We also sought guidance from the Ohio State Board of Psychology about the ethics and legality of this integration. The Ohio State Board advised us that, under Ohio Administrative Code 4732–17– 01 (G)(1)(a), when rendering psychological services as part of a team or when interacting with other appro- priate professionals concerning the welfare of a client, a psychologist may share confidential information about the client, provided that rea- sonable steps are taken to ensure that all persons receiving the information are informed about the confidential nature of the information being shared and agree to abide by the rules of con- fidentiality. As a result of these discussions and consultations, the division and the institution reached a consensus that (a) all of the medical record is to be considered confidential, and (b) hiding things within medical records can be dangerous for patient safety. CCHMC staff also felt that, as an institution, they have taken steps

to ensure medical staff members are trained in confidentiality and access of records, and had steps in place to regularly monitor access of records. Therefore, therapy progress notes cre- ated by psychologists within BMCP would be accessible to medical providers within CCHMC, including all outpatient and inpatient MDs, PhDs, nurses, and social workers. As a division, it was also determined that our psy- chologists do not keep “psychotherapy notes,” as defined by HIPAA. Once it was established that we were not using classically defined psy- chotherapy notes, integrating behavioral health records into the main medical record was deemed appropriate. A final issue to be resolved was how to handle psychological test protocols because of copyright issues, the need to keep test protocols from public access to preserve the integrity of the tests, and the sensitive nature of raw test data. We resolved this by determining that psychological test protocols and raw test data are not part of the official medical record. To keep the test protocols separate from the medical record, yet move to be totally elec- tronic, we utilized Chartmaxx. Chartmaxx is a separate electronic storage system from Epic that can be linked to Epic for documents such as school records, custody records, and so forth. This is also the system used to electronically store old paper medical records, as they are gradually being eliminated by being scanned into Chartmaxx. Chartmaxx has the capability of linking or not linking a document to Epic based on document type. HIM scans all testing protocols into Chartmaxx in a file that is not linked to Epic. Psychologists within the hospital are the only professionals allowed to access this confidential section of Chartmaxx. Thus, we have been able to become completely electronic and preserve the integrity of psychological test- ing protocols.

In the context of these discussions and deter- minations, it was also noted that there are times when allowing access to psychology notes is not clinically indicated. In the EMR there is an option of marking a specific note as “sensitive” in order to limit accessibility to particularly sensitive information shared within the context of the confidential relationship between psy- chologist and patient or guardian. Marking a psychology encounter as sensitive limits the access to that particular note to only psycholo- gists within the division (no other medical per-

20 SMOLYANSKY, STARK, PENDLEY, ROBINS, AND PRICE

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

sonnel, trainees, or support personnel). Other hospital personnel would still be able to view that an appointment had taken place, current medication and diagnoses lists, and any therapy notes not marked as sensitive. Psychologists were trained to use the designation of “sensi- tive” only for notes that contain information that could place the trust inherent in the therapeutic relationship in jeopardy, or when knowledge of the content could adversely affect how others in the institution treat the patient. Use of the sen- sitive note was left to the clinical judgment of the treating psychologist, with the caveat that consideration should be given to the fact that the designation of “sensitive” would also limit ac- cess of potentially relevant clinical information to other medical providers within the institution and so should be used with care.

After “go live,” BMCP also took a few extra steps to ensure appropriate access to records. We asked for a monthly report from HIM on who was accessing behavioral health records through Chartmaxx (linked to Epic). The clini- cal director reviews this report monthly and HIM investigates any inappropriate access. In- appropriate access has been very rare.

One challenge to an integrated EMR for be- havioral health records was preconceived ideas about the laws around confidentiality of indi- vidual psychologists and psychiatrists. Change is hard, and when that involved changes in how we interpret ethical and legal guidelines for confidentiality, it required listening to and ad- dressing concerns of the clinicians. We had many clinical discussions and updated psychol- ogists throughout the Epic build for the divi- sion. In the end, it came down to trust. At the time of the “go live,” many psychologists were not totally comfortable with the integration but trusted that the institutional and divisional lead- ership had considered the issues and were will- ing to “see how it goes.”

Four years into Epic, the hesitations initially voiced about an integrated EMR are gone, the majority of the psychologists use the “sensitive note” designation only on rare occasions, as it was designed, and the psychologists, as well as our medical colleagues, see the benefits of an integrated EMR. Because psychology and psy- chiatry are separate divisions at CCHMC, an integrated EMR has increased communication and care coordination for patients we share, as psychologists now have access to notes includ-

ing inpatient psychiatry and medication man- agement. For the psychologists imbedded in medical subspecialty clinics, using one EMR improved communication within those clinics and satisfaction with the coordination of care of complex medical patients by our medical col- leagues.

Patient feedback has been neutral to positive. Many parents are familiar with EMR at other physician offices and typically had no concerns with behavioral records in Epic. Many parents gave spontaneous positive feedback about the advantages of the psychologist having knowl- edge of visits to other doctors. Many parents shared how grateful they were to not have to repeat medication lists, and so forth. One issue we had to address was how to manage the notes if the patient was the child of an employee. In this case, we decided to give employees the option of having notes marked as sensitive. Some parents are thankful for this option; most have chosen not to have notes marked this way so that their child’s care can be coordinated across other clinics and physicians who also treat their child.

Nemours Children’s Health System/A. I. duPont Hospital for Children (DHC)

The Division of Behavioral Health is part of the Department of Pediatrics within DHC. The majority of psychologists are housed within be- havioral health, with the exceptions of neuro- psychologists housed in rehabilitation and psy- chologists who have shared appointments in other medical specialties, for example, cardiol- ogy. In addition, the Nemours Children’s Health System also includes psychologists lo- cated in children’s clinics in Florida. Similar to CCHMC, Nemours psychologists provide care on an outpatient referral model, an inpatient consultation liaison service, and in outpatient services embedded within Nemours primary care satellite clinics.

Nemours Children’s Health System began converting to EMR for outpatient services on a division by division “go live” process in 2000. At this time, a number of issues were consid- ered. Similar to CCHMC, the issues of confi- dentiality and privacy were of utmost impor- tance, and a well-qualified team of professionals participated in ongoing discussions, evalua- tions, and decision making to ensure this pro-

21BEHAVIORAL HEALTH RECORDS AND EMR

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

cess was both effective and well informed. This group included psychologists and psychiatrists from Delaware and Florida, legal counsel, the Medical Director of Health Informatics, other Epic representatives, and HIM representatives who handle releases of information to external agencies. In order to make the transition to EMR as smooth as possible for providers and families, several topics were discussed. These included the legal issues relating to HIPPA in both Florida and Delaware; the definition of therapy and progress notes; families’ rights to determine who has access to their records; the assurance that families are clearly informed about the issues of privacy and confidentiality related to their medical records; the effective use of “sensitive notes” designations; the appro- priateness of various providers viewing diagno- ses, problem lists, and medications; and the ability to monitor unauthorized access of re- cords.

Initially, both physicians and behavioral health staff had access to behavioral health notes. Similar to CCHMC, we believed that physicians were trained in confidentiality and access of records, and additional parental con- sent for these providers to access behavioral health notes was not required. However, be- cause Nemours provides services in both Dela- ware and Florida, the laws of both states relat- ing to HIPPA regulations were examined, and the more conservative law (Florida) took prece- dence. Subsequently, the decision was made for all behavioral health notes to be accessible to behavioral health staff only. Moreover, the ad- ditional level of protection for outpatient notes only applied to services scheduled within the Division of Behavioral Health. Although this applied to the vast majority of outpatient visits, behavioral health notes were not protected when patients were seen by psychologists who sched- uled through other services (e.g., General Pedi- atrics), as, similar to CCHMC, these notes were not considered “psychotherapy notes.” Simi- larly, in 2009, when our inpatient records tran- sitioned to Epic, inpatient psychological consul- tation notes were not protected because these services were considered to occur outside the Division of Behavioral Health. Due to psychol- ogists’ role as consultants to inpatient services, legal counsel felt that expectations of privacy and confidentiality differed from those of the

outpatient clinic within the Division of Behav- ioral Health.

Initial patient feedback was quite varied; some patients expressed appreciation for pri- vacy, whereas others expressed frustration that other medical providers did not have access to their records. Physicians, particularly our pri- mary care physician colleagues, initially made weekly complaints regarding their limited ac- cess to behavioral health records, as they felt this impeded their ability to provide optimal patient care. Subsequently, we developed a par- ent consent form that allowed parents to choose whether the behavioral health portion of their electronic medical record was accessible to other Nemours providers. Although initially all behavioral health notes were deemed confiden- tial until the family gave consent, the default eventually changed to all notes being accessible unless a family specifically denied consent. This system seemed to resolve both patient and phy- sician frustration.

However, even if notes are accessible to other medical providers, psychologists do have some discretion in sharing information. Specifically, psychologists can utilize a “sensitive note” function that is available through the Epic sys- tem. If a patient has allowed access to notes but reveals highly sensitive information during a session, the psychologist can mark the note for that session only as “sensitive.” Alternatively, if the session contained both sensitive information and information pertinent to patient’s medical care with other Nemours providers, the psychol- ogist can document sensitive information in a separate progress note. For example, if a psy- chologist and patient with diabetes are working on adherence concerns, information regarding goals and progress can be noted in the progress note and viewed by the endocrinologist, if the patient has granted consent for access. How- ever, if the patient or parents discussed a highly sensitive issue, a second progress note can be written for the same encounter and marked “sensitive.” Sensitive notes can be viewed only by that psychologist and others whom the psy- chologist has designated a proxy. All behavioral health clinicians are proxies for each other in order to allow coverage when needed. Like CCHMC, psychological testing protocols are not considered part of the medical record. How- ever, unlike CCHMC, we keep these protocols in paper charts.

22 SMOLYANSKY, STARK, PENDLEY, ROBINS, AND PRICE

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

We have experienced several benefits related to going to an EMR. It has increased collabor- ative care across behavioral health and medical providers. With parental consent, other medical providers involved in the child’s care have ac- cess to all records, helping to ensure integrative and collaborative care. Families do not have to repeat their history as often, and other providers are aware of mental health issues that could affect medical treatment. The EMR system al- lows for much flexibility in how notes are viewed. Importantly, it is a family-centered ap- proach, such that families have the decision- making power, along with their therapist, re- garding the accessibility of their notes by other medical staff. Most families have allowed ac- cess to their notes. Furthermore, the flexibility of the “sensitive note” function allows for some discretion on the part of the provider.

There were a few challenges to implementa- tion and to management in the face of continued growth of our medical center. Once we imple- mented a process whereby families could con- sent to the sharing of their behavioral health records as an integrated part of the EMR, the vast majority of medical staff members ap- peared satisfied with this consenting process and complaints have greatly decreased. How- ever, there remains a small minority who feel that all behavioral health records should be ac- cessible regardless of the family’s wishes. We continue to have discussions about this with both physicians and families. As behavioral health notes become part of electronic medical records, it is important that clinicians write in a way appropriate for a medical chart. We have found this writing style may be a very different style than many psychologists have used in the past and should be addressed within psychology graduate training programs to prepare graduate students for this new reality.

Because of the confidential designation for behavioral health visits (i.e., for families who have denied access to other providers), the Epic team encountered challenges regarding sched- uling of outpatient appointments. A different scheduling code must be used for families that decline to share their behavioral health visits with other medical providers than visits for fam- ilies who have granted access. Therefore, sched- ulers must know in advance how a visit should be scheduled within Epic. In addition, processes to inform families, gain signed consent, and

document these procedures had to be designed and implemented. Additionally, behavioral health clinicians must approve any release of information request that comes through HIM.

One potential upcoming challenge concerns access for school nurses. Nemours has launched a new program that allows school nurses to have access to Epic, contingent on families’ consent. However, although families may want school nurses to have access to diabetes regimens or asthma medications, they may be uncomfort- able with school nurses having access to behav- ioral health therapy notes. At this initial stage of development, behavioral health notes, but not di- agnoses, cannot be viewed by the school nurses. We are certain this will continue to be a topic of discussion.

The Children’s Hospital of Philadelphia (CHOP)

The Department of Child and Adolescent Psychiatry and Behavioral Sciences (DCAPBS) is one of six departments within CHOP. It is the discipline-specific home for all licensed psy- chologists, child and adolescent psychiatrists, licensed clinical social workers, and licensed behavioral health practitioners within CHOP. With over 90 licensed mental health providers across two states, psychologists provide ser- vices within medical inpatient, medical outpa- tient, mental health outpatient, integrated pedi- atric primary care, and satellite subspecialty care settings. Departmental policies and proce- dures, including use of the electronic medical record for behavioral health documentation, ap- ply to all CHOP licensed behavioral health pro- viders, regardless of their physical location or department/division affiliation. That is, the Epic security profile is determined by role, not phys- ical location within the hospital system.

Similar to CCHMC, the EMR rollout at CHOP was a multiyear process. Divisions “go live” as their build is complete, on a rolling basis. DCAPBS, the home for all licensed psy- chologists, psychiatrists, and clinical social workers, went live in October 2012. DCAPBS has many …