The latest research suggests that preventing psychiatrists from sharing their patients’ records with their other doctors may actually do more harm than good.
Some of the most sensitive information in medicine involves mental health care, including the diagnoses, drugs and notes that psychiatrists include in their patients’ health records. The files can include anything from dosage of medications to people’s deepest fears and their most bizarre fantasies. So both regulators and health care professionals go to great lengths to keep such records private and for certain eyes only.
But in a study published in the International Journal of Medical Informatics, researchers found that hospitals that both use electronic psychiatric records and allow them to be shared with other doctors have a 32% to 39% lower rate of readmission within a month of patient discharge for mental illnesses.
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“Those hospitals that actually coordinate care between psychiatrist and nonpsychiatrist physicians, presumably through electronic records, had better outcomes,” says lead author Dr. Adam Kaplin, assistant professor of psychiatry and neurology at Johns Hopkins.
“I thought it was an interesting study, and it fills a void in terms of information” about these outcomes, says Dr. Norman Clemens, a psychiatrist in private practice who has studied privacy issues in psychiatry but is not associated with the new research.
Kaplin and his colleagues analyzed data from 13 of the 18 hospitals listed by U.S. News & World Report as the best in America. They found that less than half (44%) of these top hospitals used electronic records for psychiatric care, and only 28% allowed physicians in other specialties to look at the psych records of the patients they were treating. A mere 22% did both, which meant that only this group had rapid access to the information through computerized records.
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The study was prompted by Kaplin’s personal experience with the detrimental effects of these barriers. When his neurology colleagues wanted to consult his psychiatric records, it often took six months for them to be allowed access to essential information about medications he prescribed that could potentially interact with their other treatments. While there is no regulation that mandates separating psychiatric records from other medical files and keeping them more private, given the personal nature of the disclosures during therapy sessions, many institutions apply stricter access requirements to mental-health information in order to protect the privacy of patients. Asking the patient could help, but patients do not always accurately recall the names and doses of drugs they take. Not having full access to a patient’s health records, including those involving his or her mental health, could lead to potentially serious and even fatal drug interactions, Kaplin says.
Kaplin and his colleagues collected data from the University HealthSystem Consortium Clinical Data Base to determine the percentage of psychiatric patients readmitted to the hospital for any reason at three time periods: within a week, two weeks or a month after their discharge. They used readmission as an indicator that something had gone wrong in the patient’s care, such as a problematic drug interaction or a treatment failure.
The results weren’t particularly surprising, since electronic medical records are supposed to improve efficiency and accuracy of information sharing. “The implication is that electronic records promote the ease of sharing information, [leading to better results],” says Kaplin. “That’s not a shocker but it brings up an important issue: if this is so obvious, why are only five out of 18 of the best hospitals in the country sharing these records and only four of 18 electronically storing them and sharing them [as well]?”
Some of the resistance may be tied to the lingering stigma of mental illness and fears that people who most need treatment — and may pose a danger to themselves or others — may not seek care if they believe what they reveal to their doctors will be accessible to others.
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Still, Kaplin believes segregating psychiatric care from the rest of medicine only reinforces such thinking. If psychiatric illnesses are treated with the same medical decorum as other medical illnesses, such as cancer or heart disease, why shouldn’t all the doctors treating a patient have access to these records? Failing to do so, he says, can lead to worse health outcomes: patients who have had a heart attack, for example, are at greater risk of depression and a slower recovery, but if the cardiologist treating the heart attack doesn’t have the psychiatric records that note a history of depression, then he is missing critical information that might require more intensive monitoring and treatment.
“Having depression in the year following a myocardial infarction is the No. 1 predictor as to whether someone’s going to die of a lethal arrhythmia,” says Kaplin. “It’s as important or more important than smoking or high cholesterol. Who are we protecting [patients] from if a cardiologist doesn’t know that a patient is depressed? Why is clinical depression more sensitive than having urinary incontinence or STDs or a penile implant?”
Clemens, however, argues that there are certain parts of psychiatric records that are highly sensitive and should not be shared, including the therapeutic notes taken during talk therapy, which can reveal things such as extramarital affairs or potentially embarrassing fantasies and thoughts. While he agrees that prescription and diagnostic information should be made readily available to consulting physicians, he believes notes taken during in-depth talk therapy don’t carry the medical implications that prescriptions and diagnoses do. “That does not belong in a medical record, and there should be very clear and active patient consent required for [releasing] it,” Clemens says. Kaplin agrees that therapeutic notes with potentially damaging information should not be shared.
Both also believe computer systems for medical records should carefully track who accesses the information, to ensure that the most private data remain protected and to deter those who would misuse them.
These findings should inform how health records are used and shared in the coming years as the Affordable Care Act goes into effect. Studies like this one suggest that integrating them across specialties can not only improve care but also cut costs, which makes the challenge of protecting medical data — particularly the most sensitive — even more important to face.