Contemporary Ethical Issues in Behavioral Health Care

1. Session # B2a October 28, 20111:30PM Contemporary Ethical Issuesin Behavioral Health Care Tai J. Mendenhall, PhD, LMFT, CFT Assistant Professor & Coordinator of Behavioral Medicine Education, University of Minnesota Medical School Kenneth W. Phelps, PhD, LMFT Assistant Clinical Professor, University of South Carolina School of Medicine Keeley J. Pratt, PhD, LMFT Post‐doctoral Fellow in Personalized Medicine, Obesity Signature Program, RTI International Angela L. Lamson, PhD, LMFT, CFLE Associate Professor and Director of MFT (MS) and MedFT (PhD) Programs, East Carolina University Jennifer L. Hodgson, PhD, LMFT Associate Professor, East Carolina University Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap Multi- / inter- disciplinary collaboration allows for an enhanced view of “the system,” but… At the same time, it opens the door for ethical violations in care. • Risks increase when behavioral providers work with biomedical providers • Risks can be further exacerbated according to the type(s) of medical environment in which the work is positioned (e.g., outpatient vs. inpatient facilities, acute care vs. long-term settings) • Challenges are influenced by personal- and virtue- ethics (e.g., culture, gender, politics, religion)

4. Objectives To introduce common ethical challenges in delivering behavioral health care within integrated and collaborative environments To discuss the challenges of misinterpreted communication, confidentiality and disagreements in treatment goals Process the additional role(s) of personal- or virtue- ethics in collaborative care

5. Expected Outcomes At the conclusion of this workshop, participants will be able to: Describe how the complex nature of integrated care environments sets the stage for ethical violations in care-provision Describe common ethical challenges across outpatient and inpatient integrated care settings Apply communication tools to enhance ethical collaboration with healthcare providers and patients Describe the roles that personal or virtue ethics play in the delivery of integrated care

6. Ethical Challenges when Growing from Coordinated to Integrated Care

7. * * * * * * * * * Sharing of facilities, systems, communication, culture, power * * * * * * We also teach others how to be a team and design the care system I am your consultant You help me as well as my pts. No one knows my name Who are you? I help your pts. You help my pts. but not me MH We are a team in the care of our patients Med Levels of Care 1 2 3 4 5 Close collaboration in partly int. system Close collaboration in fully int. system Minimal collaboration Basic collaboration at a distance Basic collaboration on-site Doherty, McDaniel, & Baird (1996) CJ Peek, PhD

8. Ethical Implications of the Levels Minimal collaboration Is information being shared at all? Are releases being obtained for communication? Basic collaboration at a distance Is information being shared in a timely manner? Are releases being obtained for communication? Is information communicated confidentially? Are providers communicating in a professional, respectful manner?

9. Ethical Implications, con’t Basic collaboration on-site Are consults being handled in a timely fashion? Is there communication after a referral? If so, is communication conducted in a confidential, respectful way? How do providers respond to inquiries from those not involved in direct care? Do treatment plans influence each other?

10. Ethical Implications, con’t Close collaboration in partly integrated system Does the “team” maintain appropriate professional boundaries? Do the members of the team stay within their own skill sets? Is there appropriate follow-up by each team member? How does the “team” handle disagreements?

11. Ethical Implications, con’t Close collaboration in fully integrated system Does care of the system avoid inappropriate therapist/ provider-staff relationships? After team members share knowledge, do they operate within their own clinical capabilities? Are team members acting cohesively? Are team members operating in the best interest of the patient, incorporating all team members’ perspectives?

12. IOM Aims Meet Technologyin Health Care • Safety: consider electronic entry for medications and diagnoses to reduce the lethal errors. • Effectiveness: use of automated reminder systems may increase treatment show rate and outcomes • Patient-Centered: use of telemedicine, e-mail contacts, on-line support sessions • Timeliness: automated clinical information, collaboration between providers through telemedicine or e-mail • Efficiency: tracking encounters and time spent with patients as this compares to patient outcomes • Equity: using practice based research networks to maximize comparisons within and between practices and their populations

13. Use of Cyber Notes/Contacts and Ethics • Other persons who have access to the client's email, such as employers or family members, may be able to read stored copies of the client's email or incoming email from the therapist. • Online mental health clients also need to consider the possibility that email records may be subject to subpoena. • This possibility of emotional injury and re-traumatization may be further exacerbated by the increased self-disclosure and disinhibition associated with online communication . • Mental health professionals wishing to practice online also need to consider their legal authority to practice in a jurisdiction in which they are not licensed to practice.

14. Cyber Notes/Contacts and Ethics, con’t • Therapists seeking to practice online must evaluate what steps will be taken to verify the age of clients so as to not treat minors without the knowledge and consent of their parents. • Online psychotherapists need to consider plans for addressing the variety of crises that may present in therapy including suicidal clients, physical and sexual abuse, threats to harm others, and the possible discovery that the client's issues would more appropriately be addressed with intensive in-person therapy or hospitalization. Childress, 2000; Holland, 1996; Newman, Consoli, &Taylor, 1997; Seeman, 1999

15. E-mail Context and Ethics • Interactive text-based communication also involves the loss of the non-verbal social cues that provide valuable contextual information in conversation and can influence the interpretation of meaning in communication. • Miscommunication may therefore be more likely with interactive email communication. • Lack of monitoring non-verbal communication could lead to underdiagnosing/misdiagnosing

16. Kane &Sands: Top 10 Do List 1) Establish turnaround time for messages. Do not use e-mail for urgent matters. 2) Inform patients about privacy issues. Patients should know: • Who besides addressee processes messages • During addressee’s usual business hours • During addressee’s vacation or illness • That message is to be included as part of the medical record 3) Establish types of transactions (prescription refill, appointment scheduling, etc.) and sensitivity of subject matter (HIV, mental health, etc.) permitted over e-mail. 4) Instruct patients to put category of transaction in subject line of message for filtering: ‘‘prescription,’’ ‘‘appointment,’’ ‘medical advice,’’ ‘‘billing question.’’

17. Top 10 Do List, con’t 5) Request that patients put their name and patient identification number in the body of the message. 6) Configure automatic reply to acknowledge receipt of messages. 7) Print all messages, with replies and confirmation of receipt, and place in patient’s paper chart. 8) Send a new message to inform patient of completion of request. 9) Request that patients use autoreply feature to acknowledge reading provider’s message. 10) Maintain a mailing list of patients, but do not send group mailings where recipients are visible to each other. Use blind copy feature in software.

18. The next steps in cyber notes…EHR

19. The Electronic Health Record (EHR) is • a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. • information on patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. • a complete record of a clinical patient encounter: as well as supporting other care-related activities directly or indirectly via interface: including evidence-based decision support, quality management, and outcomes reporting. • Healthcare Information and Management Systems Society (2009)

20. NIH- National Center for Research Resources

21. NIH- National Center for Research Resources

22. NIH- National Center for Research Resources

23. Electronic Records and HIPAA • In December of 2000, DHHS announced legislation implementing comprehensive privacy protection related to patient medical record information.

24. DHHS-8-1-2006 On August 1, 2006 Health and Human Services (HHS) Secretary Mike Leavitt announced final regulations establishing rules intended to support physician adoption of electronic prescribing and electronic health records. The final regulations became law on October 10, 2006. Federal Register/Vol. 71, No. 152/Tuesday, August 8, 2006/Rules and Regulations, 45113

25. Ethical Concerns with the Current EHR Systems • Lapse times between system to system delivery • Technology assistants who are off site but can get access into your computer • Damage to Archives • Security Risks within work contexts (e.g., where are computers located and can patients log on and change data or look up other’s data in waiting rooms or patient rooms) • Potential loss of data • Upfront costs of EHR system and technology (e.g., computers) • Human error in data entry • Kickbacks between systems

26. Important Points for EHRs • The quality of the information in electronic patient records depends directly on the quality of data currently being recorded in paper-based records • Standards for clinical recording are needed to assure that consistent data are recorded in a structured and timely manner • The development of standards must be led by clinicians rather than managers**** • There must be assigned responsibility and accountability for recording of patient data • Continuous monitoring of patient data is needed to assure standards are met Huston, 2004

27. Important Points for EHRs, con’t • Points about billing: • Consider who has access to encounters • How are diagnoses documented in the system • How are credentials of the provider documented • What are policies on inability to pay • Example: patient was not allowed to return for any medical services at Site X until payments on account were made.

28. Important Points for EHRs, con’t • Supervision considerations: • How is accountability on interoffice e-mail managed when it includes patient information • How are collaboration, ethics, and liability managed when mental health notes are locked or not considered as part of the larger medical file • Who is signing notes (administrative supervisor/offsite supervisor) • Have releases been addressed for all those who have access to any part of the EHR. • How are files “terminated”

29. Common Ethical Challenges Across Settings

30. Outpatient Adult SpecialtyMediators to Ethical Care Barriers Mediators • Personal/Family • Acceptability • Cultural • Language/literacy • Attitudes/beliefs • Preferences • Involvement in care • Health behavior • Education/income • Structural • Availability • Appointments • Organization • Transportation • Financial • Insurance coverage • Reimbursement level • Public support Outcomes Use of Services • Quality of Providers • Cultural competence • Communication skills • Medical knowledge • Technical skills • Bias/stereotyping • Appropriateness of care • Efficacy of treatment • Patient adherence • Health Status • Mortality • Morbidity • Well-being • Functioning • Equity of Services • Patient Views of Care • Experiences • Satisfaction • Effective partnership(s) • Visits • Primary care • Specialty care • Emergency care • Procedures • Preventive • Diagnostic • Therapeutic Cooper, Hill, & Powe (2002)

31. Common Ethical Challenges across Outpatient and Inpatient Care Settings • Different codes of ethics • Triangulation • Care consulting and advocacy • Confidentiality vs. disclosure • Scope of practice issues • Dual relationships • Cultural sensitivity • Stigma

32. Common Ethical Challenges, con’t • Conflicting approaches to behavioral health change • Labeling/stereotyping patients or providers without full evaluation or assessment • Practicing in isolation • Lack of mental health/substance abuse assessments

33. Common Ethical Challenges Unique to Inpatient Settings • Insufficient amount of therapy provided to prepare patients and family for discharge or address psychosocial issues • Insufficient number of psychiatrists available outpatient to continue complex medication protocols • Medical stabilization versus in-depth treatment • Determining who to admit and when to discharge • Shared patient rooms • Lack of communication between hospitalists and PCPs; inpatient psychiatrists and outpatient mental health providers

34. Ethical Code Resources

35. American Psychological Association • http://www.apa.org/ethics/code/index.aspx • 5 General Principles • Beneficence and nonmaleficence • Fidelity and responsibility • Integrity • Justice • Respect for people’s rights and dignity • 10 Specific Ethical Standards

36. American Association for Marriage & Family Therapy • http://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx • 8 Principles • Responsibility to clients • Confidentiality • Professional competence and integrity • Responsibility to students and supervisees • Responsibility to research participants • Responsibility to the profession • Financial arrangements • Advertising

37. American Medical Association • http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page • 10 Principles of Medical Ethics • Introduction • Opinions on social policies • Opinions on inter-professional relations • Opinions on hospital relations • Opinions on confidentiality, advertising, and communication media relations • Opinions on fee and charges

38. AMA, con’t • 10 Principles of Medical Ethics con’t • Opinions on physician records • Opinions on practice maters • Opinions on professional rights and responsibilities • Opinions on the patient-physician relationship

39. Principles of Medical Ethics • I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. • II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. • III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. • IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. • V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

40. Principles of Medical Ethics, con’t • VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. • VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. • VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. • IX. A physician shall support access to medical care for all people. • Adopted June 1957; revised June 1980; revised June 2001.

41. American Nursing Association • http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.aspx • 9 Provisions

42. National Association ofSocial Workers • http://www.naswdc.org/pubs/code/code.asp • 6 Core Values • Service • Social justice • Dignity and worth of the person • Importance of human relationships • Integrity • competence

43. Enhancing Ethical Communication

44. Preparation • Learn one another's primary professional language and adopt common vocabulary • Know limits surrounding HIPAA and state laws for sharing information • (Virtue Ethics) Awareness of personal viewpoints and conceptualizations • Negotiate who needs to ask the tough but important questions • Have the right forms and assessments readily available • Read EMR prior to collaborative encounter if possible

45. Protocol • Assessments to screen and track change in mental health status • Define model being used in practice or per provider • Negotiate communication protocol before, during, and after visit • Release and receipt of information • Read one another’s EMR notes and secured emails • Ask who the patient is and who his or her “family” includes • Incorporate patient’s support system into treatment plan, especially when requested by patient or for a minor • Document and diagnose according to billing and reimbursement regs

46. Process • Observe metacommunication about care and communication sequences • Positive reinforcement • Follow up with inpatient/outpatient providers and family/support system actively involved in patient care, appoint a lead person on team for this role • Debrief and refine protocol to improve • Orient new providers and do not assume understanding or experience

47. Structure/Resources • EMRs, task-lists • Awareness of location of conversations • Exams rooms that accommodate patient needs • Time for staff/team meetings to discuss patient care • Annual trainings on ethics

48. Discussion / Q & A

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