Do missing mental health notes undermine EHRs?

As medical records move to the electronic world, a long-standing tradition has carried over from the days of paper: separating psychiatric records from the rest of patient information.

The American Psychiatric Assn. and others are calling for the separation to end. They want patients to have the ability to share their mental health records with other physicians and care team members in the same way the rest of their records are managed.

Although many agree that patients should be able to share the records, and evidence suggests that doing so could lead to better and safer care, the issue largely has been avoided because of technical complexities with the selective consent process needed to give patients control. Experts say the wider sharing of psychiatric records will require greater patient education as well as physician education about who sees what in the records.

Many organizations have outdated views about how mental health records should be handled, said Adam Kaplin, MD, PhD, assistant professor of psychiatry and behavioral sciences and assistant professor of neurology at the Johns Hopkins University School of Medicine in Baltimore. He said many make inaccurate assumptions about what laws say about patient privacy and mental health. As long as the medical community treats mental health records differently from other records, the stigma that led to their separation will continue, and patients could receive subpar care, he said.

How often records are shared

Dr. Kaplin said that as more organizations go electronic, he and fellow researchers at Johns Hopkins wanted to get an idea of how health care systems shared the records. “We are doing terribly,” he said.

Researchers examined how the top 18 hospitals in the U.S. in 2007, as defined by U.S. News & World Report, were handling psychiatric records. They found that only 44% store psychiatric records electronically, and 28% share the records with nonpsychiatric physicians.

The researchers then compared the readmission rates of 2,000 psychiatric patients at the 18 hospitals and found that those that shared psychiatric records with nonpsychiatrists had significantly lower patient readmission rates at seven, 14 and 30 days after discharge.

The Johns Hopkins researchers looked at only psychiatric records. But the consent process also is complicated for other areas of medicine, including HIV status and substance abuse, which may have state laws governing how records are shared. The results were posted online Dec. 19, 2012, by the International Journal of Medical Informatics.

“The psychiatric illnesses these patients have play a huge bearing on their medical illnesses,” Dr. Kaplin said. “As an example, whether or not you have depression following a heart attack is as big as or bigger than any other risk factor as to whether you are going to die in the year following that heart attack.”

Dr. Kaplin said a safety issue is involved as drug-to-drug interactions for someone on antipsychotic medication can be life-threatening.

“So it is not, 'Gee, it would be sort of, maybe nice if they know.' You're not going to be able to give or get the care that the patient really should expect from their team unless nonpsychiatric physicians have access to their records,” he said.

Many patients have expressed concern that they are being discriminated against because they are not receiving the same level of care as other patients.

“It is health,” said Kait B. Roe, a patient advocate and patient engagement consultant in Washington. “It is the health of the whole person that matters, and until we can get past all of this stuff that is attached to mental illness, we will never have parity in how we treat patients.” (See correction)

Privacy worries persist

Roe said she supports the full sharing of records with everyone involved in a psychiatric patient's care. But she said some patients have “absolutely valid” concerns about where their psychiatric records will end up. (See correction)

Some patients fear that their records will be used against them, said Shawn Alfreds, chief operating officer of HealthInfoNet, the statewide health information exchange in Maine. This is of particular concern given the ongoing debate about gun rights and the Obama administration's efforts to implement wider restrictions on gun ownership.

Steven Daviss, MD, chair of the American Psychiatric Assn.'s Committee on Electronic Health Records, said there is very little chance the wider sharing of records would lead to more patients being declared unfit to own a gun. But there's a great chance that fear could prevent many from seeking care.

A lot of the concerns associated with sharing records could be alleviated with patient education, said John Grohol, PsyD, who founded Psych Central, an online patient community.

“In a medical record, psychiatric information tends not to be as detailed as patients might believe it to be,” he said. “They assume … if they talk about X, Y and Z with their therapist at the hospital or with a psychiatrist it will be in the record, and in most case that's simply not true.

“Once a patient sees their medical record and actually reviews it with a doctor or psychiatrist, they will be put at ease.”

Dr. Daviss said the APA supports having patients control who accesses their records.

“We are a long way from discussing the nitty-gritty of what should be shared,” Dr. Kaplin said. But at the very minimum, other physicians should know the name of a patient's treating psychiatrist, the diagnosis, the medications he or she takes, and whether he or she is suicidal, he said.

Addressing the issue

Many health care organizations and health information exchanges have had difficulty compiling complete records that allow patients to designate what mental health information they want shared, and with whom.

The difficulties are both technical and logistical, because many organizations and their EHRs let patients share only all or none of their records. Neither their policies, nor their EHRs, are designed to assign different levels of access to different parts of the records. The APA has published an action paper for health information exchanges to address the issue and is working to develop policy on how it should be handled.

HealtInfoNet is working on integrating mental health records with other records thanks to a grant from the Center for Integrated Health Solutions, which is funded by the Substance Abuse and Mental Health Services Administration and the Health Resources Services Administration. CIHS awarded grants to five states to help support the sharing of records.

But even with money in hand, the task has been difficult to handle because of state laws requiring two separate patient consent models — one for physical health and the other for mental health. HealthInfoNet is taking it in incremental steps, starting with sharing continuity of care records, Alfreds said.

Dev Culver, executive director of HealthInfoNet, said: “The real challenge for us going forward is to continue to walk that line between being effective in helping to coordinate care and being sensitive to the fact that consumers all have different levels of senses to exposure and risk.

“It's like investing,” Culver said. “I may be a very conservative investor, and you may be a very not-so-conservative investor, and that's because we have different tolerances for risk. And how do you measure the risk of such an amorphous thing?”