Confidentiality of behavioral health records in the EMR
I was wondering how people handle confidentiality of records in the EMR? We use Cerner but some of my questions would apply no matter which EMR was used. When the BHC documents are the notes then "blind" to the physician in the same way that a behavioral health note written in an outpatient behavioral health setting would be blind? If not, how do you ensure that only the physician/provider can see them? We are worried about the admin staff being able to see confidential BHC documentation.
Thanks so much,
Several programs allow you to have setting where different providers/admin/groups must "break the ceiling" to get into BHC notes. Breaking the ceiling provides the person about to access the record information that these are confidential records and are only for those with a distinct need to know. The program then tracks when someone breaks the ceiling and you can monitor if a rogue individual is being nosy.
RobynneOur BHC notes are not glass protected or blind to the PCP – I want the provider to read our assessments! They are less likely to do this if they have to break glass each time. Our patients know that BHCs function as a part of their medical team, not a separate service, so our documentation reflects that.
As such, there’s no way for us to prevent unauthorized viewing 100% of the time, outside of the protections already in place for a patient’s medical chart. In our clinics, I’ve noticed that PCP notes FAR out detail sensitive information compared to BHC notes (e.g., PCP writes “raped by uncle”, BHC writes “h/o sexual assault”) -- so glass protecting them doesn’t truly make sense – the sensitive information already exists in the PCP notes.
If you’re separately worried about content in BHC notes, I’d ask; 1) is the content truly more detailed, salacious, etc compared to PCP notes? - and if so, 2) perhaps re-tooling how BHC notes are written, making them more appropriate for a medical record may be needed. It’s when BHCs carry over lengthy specialty mental health habits that notes become unnecessarily detailed. I train my BHCs out of this habit when they come on board.
I hope we are moving to a time when the model of treatment that many of us use is not so focused on “pathology” and can be more focused on learning more useful ways of coping. We had better be taking steps in that direction because the days of notes that the patients don’t read are ending. Currently 43,566,000 people have access to the notes from their doctors online. See www.opennotes.org . Both physicians and BH clinicians will have to learn to write notes that the their patients can read. I found that for 20 years of my clinical work, the best way to keep from having any problems with notes was to read the note from the last visit whenever the patient came for another visit. It meant I wrote notes that I hoped they would hear, ones that were positive clinical interventions as well as documentation.
And the groups of patients who most benefit from reading those notes are the multiply-disadvantaged patients with the most traumatic histories. For a more complete exposition, see Blount, A. (2019). “T” is for transparent. In A. Blount, Patient-Centered Primary Care: Getting from Good to Great, www.Springer.com
Thank you, Sandy, for saying what needed to be said. Honor the courageous. Btw, your book is excellent.
Peggy Better yet train the staff regarding “permissions”, you can limit who can see notes by department/degree and then follow-up with log in audits for spot checking compliance with the note access policy.
We use Centricity which allows us to create user groups and have the BHC notes marked as Sensitive. This allows only the clinical folks (PCP, RNs, etc.) access but does not allow non-clinical such as the front desk staff etc. Non-clinical staff can look within appointments to see if the patient had a BHC visit just cannot see the content of the note. Clinical staff do not have to do anything different to obtain access it is all included in what they can see in the chart.
Since we have a lot of community folks work at our clinics, this ensures that friends are not looking at friends charts.
It is important that the workflow is not different for any of the providers. We also updated our Confidentiality policy which includes information about authorized use, unauthorized use (such as snooping).
I’m late to the party on this topic but thought I’d add my thoughts. We have discussed this at length as well but we have decided to treat our BH consult notes in the same manner that every other chart note is handled (not marking as sensitive). Our worry is that by marking BHC notes as sensitive, confidential, or private it will only perpetuate the entrenched stigma associated with behavioral health issues by sending everyone the message that these consults and problems are “different” from other health issues and BH clinicians are also “different” from other providers.
In our system we are trying to educate everyone (staff, providers, patients) that these are common health issues that need to be normalized, discussed, screened, treated, addressed in a variety ways—they are not shameful issues that need to be hidden or treated with a higher level of sensitivity.
There are a wide variety of health conditions that are serious and need to be addressed but are also potentially embarrassing or difficult for people. I’d bet money that there are a lot of people who be more sensitive about their anal fissures chart note vs. their anxiety chart note.
Thank you so much for everyone who reached out to me about my question about confidentiality in the EMR. I was able to present your feedback to my administration who now "see the light!" Thank you thank you thank you!!!