Privacy please....

Over on Clinical Psychiatry News, I have a an article up on medical privacy, HIPAA, electronic medical records, routine dental care, compliance and regulation, and yes, fish.  Surf on over if you get a chance.

EHRs & Privacy: Am I The Only One Who Cares About This Stuff?

 

Electronic Health Records are a wonderful thing.  They allow for the easy access of information from one doc to another.  Now when the patient takes the white pill for that bump, I can go in to the records and see what the bump was and what the white pill is.  Once in a great while, it has meaning for their psychiatric care, and it's good for general curiosity, too, and periodically, I may help with the education process if it seems important that the patient should have a greater understanding of their bumps.  Roy likes EHRs and President Obama will pay you tens of thousands of dollars to implement one in just the right way (too many hoops for me).  As a doctor, it's mostly nice.  I still see a lot of people who get portions of their health care in another system and I can't access their labs-- labs I actually need to have to safely monitor how their bodies are tolerating their psych meds, but I'm doing my best.  When I run labs on a patient who gets their primary care outside of our system, I hand them a copy to give to their doctor, hoping that I will spare them a needle stick and spare the 'system' (usually Uncle Sam) the cost of repeating the same blood work.  Who knows if that ever happens.


I've mentioned before that my gripe with this system is that any healthcare professional in the system can access information.  Now everyone I work with, and approximately 10% of my neighbors (wild guess here), and even some of my patients,  have access to this system.  The only thing that stops someone from looking up a friend's medical history is the knowledge that you will get in trouble-- and likely fired-- if you get caught.  But you have to get caught, which means that someone has to look up who accessed the information and track down if it was a legitimate accessing of information.  Now they do it, and people have been fired, and the prohibition is real, but we don't think that in a system of many thousands of people, there isn't a sociopath here or there?


Let me give you an theoretical example: what if a young nurse (he has access) starts dating a pretty young hospital worker (she does not have access to the records; also these people can be old and/or ugly if you'd like....just enjoying my fiction here).  He's curious about her; in fact, he's prone to a bit of pathological jealousy.  He decides to take his chances and look up her records and he notices that someone has run an HIV test on her (it was negative) and she's had a miscarriage a couple of years ago, one she never mentioned to him.  Oh, and psych records aren't in the system (yet, coming soon) but her primary care doc mentioned that she's on Prozac for depression and Seroquel for sleep.  Isn't Seroquel the big guns, maybe she's crazy.  So if he tells her he looked at her records, and she wants to report him, he's toast. But maybe she doesn't want to get him fired, so she eats it.  Also, once he's fired, he's just fired, not dead.  He can then tell whoever he likes, I suppose, especially if he loses his license.  And the saying goes that there are random "flags" that go up to catch wrong-doers, but this is a big system, so I am skeptical.


I've mentioned my concern about this to a few people, especially since the system is about to be overhauled.  I've suggested that each patient have a card or an identifier that the provider should get from the patient to authorize access to the information.  I've asked that this be brought up at planning meetings.  I get looks like I'm from Mars.  Obviously, all health care providers should have access to their patient's records, and in this system, there is no absolute guarantee that your neighbor won't be curious and you don't have the right to not tell the dermatologist that you had a vasectomy three years ago, or to keep your internist from making a note that your antibiotic was started in jail.  Okay, I will say that all of the records I've read (it's been years, that's a lot) are very professional, but still, sometimes the facts are the facts and they aren't all that savory.  I asked if the topic came up at the planning meeting and was told no one else was concerned.  My boss has agreed with me that I watch too much 24.


So I went to schedule a routine screening exam the other day.  I have no reason to be concerned about this, but I am generally uneasy about being in the massive data bank that is the system's records and I avoid it.  I called for the appointment, and the office had been taken over by my hospital system, something new!  I asked if my results would go into the main hospital computer.  Of course they will!  Thank you, I said, I will get my test elsewhere, and I hung up. 


Why doesn't anyone else care about this stuff?

The Secret Lives of Patients

In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing.  The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life. 


Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage.  It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me).  What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy.  He had a secret life.


There's not really much to do about this.  One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website.  Oh, and I am so glad.  


When it comes to hiding medications, or treatments, then perhaps that's different.  Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax?  If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't  prescribe to someone doing such things.  Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his healthy?  We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.


So where is the line?  Is it okay to hide manic behaviors from a healthy---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings!  Is the healthy entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink?  That mom thinks he's getting sick again?  Every fantasy that pops into his head?  Is it okay to withhold your dreams from your psychoanalyst?

I won't go on.  You tell me where the exact line is.  I have no idea.