Keep Out! Privacy, Collaboration and Behavioral Health Integration

1. Keep Out!Privacy, Collaboration and Behavioral Health Integration Susan D. Wiley, MD Vice Chairman, Department of Psychiatry Lehigh Valley Health Network Gail Stern, MSN, PMHCNS-BC Administrator, Department of Psychiatry Jamie Bongiovi, LCSW Program Director, The Guidance Program Session # B6b October 6, 2012 Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

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

3. Objectives Participants will be able to: 1. Identify two legal mandates for patient privacy protection. 2. Name 3 benefits of sharing patient information. 3. Identify 2 key elements of patient privacy protection in Behavioral Health Integration.

4. Learning Assessment We welcome your questions during the session and will leave 10 minutes at the end of our presentation for questions and discussion.

5. Who We Are Largest academic community hospital in PA Largest Level 1 Trauma Center in region Certified Stroke Center Employees – 10,200 Medical Staff – 1,200+ Nurses – 2,334 Magnet Hospital 163,000 ED visits 68,602 admissions 981 acute care beds 3 hospital campuses Revenues over $1 Billion

6. Advantages of the EMR Automation improves access to records Reduces medical errors Facilitates screening and tracking of patient progress Fosters collaboration between medical and behavioral health providers Shared information reduces duplications of effort and saves money and time

7. Why do we need to respect patient privacy? “Whatsoever things I see or hear concerning the life of man, in any attendance on the sick or even apart therefrom, which ought not to be voiced about, I will keep silent thereon.” (Oath of Hippocrates)

8. “Effective psychotherapy depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories and fears. For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment.” B. Rock

9. Elements of privacy, and confidentiality • Privacy vs Confidentiality • Qualifiers: • Real Risk • Serious Harm • Imminent Risk • Effective Intervention • Public Interest/Health

10. What are the legal responsibilities, mandates for privacy? • Confidentiality of mental health records is governed by: • HIPAA (the Health Insurance Portability & Accountability Act) of 1996; • Various CMS and Joint Commission regulations; • Your state Department of Health standards; and • Your state mental health laws.

11. “Sensitive Information” and “Sensitive People” • Is behavioral health information different than other clinical information and how? Should it be? • What are the pros and cons of handling behavioral health information differently than other kinds of medical information? • Are there “sensitive people” that require a higher level of privacy?

12. Provider Concerns: • Medical • Behavioral Health • Traditional • Integrated

13. Patient Privacy Concerns Access: Who can access my records? • Personal Issues: Can I protect sensitive information I don’t want anyone to know? • Stigma: I don’t want people to discriminate against me. • Can my employer see my records? • Can my records be used by the criminal justice system or affect my insurance benefits? • What if someone unauthorized sees my records? • Survey Results

14. LVHN Story: Our experience and process • Confidentiality Committee • Physician review and input • Policy formation • Patient privacy protections • Education • Audit and enforcement

15. Documentation in Collaborative Care • For the provider to trigger their own memory • For the patient to understand their care • For other providers to understand the care you are giving • For billing and compliance purposes • For the attorney who may defend you

16. Key Steps in Developing an EMR • Establishing a multidisciplinary Confidentiality Committee • Determination of what information is to be retrievable for PI • Identification of critical information categories to be shared for patient safety • Identification of critical information categories to be held privately • Identification of information to be shared for the promotion of public health

17. Key Steps in Developing an EMR • Means to handle sensitive information sensitively • Determine access level and entry privileges by job description • Provider Education • Patient Education and Consent Process • Audit and Enforcement • Evaluation and Revision

18. Discussion and questions: • How does sharing information change the information that is shared? • Who is the owner of the health records, patients or providers? • How do we juggle sensitive medical and BH information in the examination rooms?

19. References and Resources • SAMHSA http://www.samhsa.gov/healthIT/ • PCPCC http://www.pcpcc.net/health-it • AHRQ http://www.ucguide.org/index.html

20. References and Resources 1. Yang Y; Han X; Bao F; Deng RH. A smart-card-enabled privacy preserving E-prescription system. IEEE Transactions On Information Technology In Biomedicine: A Publication Of The IEEE Engineering In Medicine And Biology Society [IEEE Trans Inf Technol Biomed] 2004 Mar; Vol. 8 (1), pp. 47-58. 2. Ayatollahi H; Bath PA; Goodacre S Accessibility versus confidentiality of information in the emergency department. Emergency Medicine Journal: EMJ [Emerg Med J] 2009 Dec; Vol. 26 (12), pp. 857-60. 3. Stewart RF; Kroth PJ; Schuyler M; Bailey R. Do electronic health records affect the patient-psychiatrist relationship? A before & after study of psychiatric outpatients. BMC Psychiatry [BMC Psychiatry] 2010 Jan 08; Vol. 10, pp. 3. Date of Electronic Publication: 2010 Jan 08. 4. Fetter MS. Electronic health records and privacy. Issues In Mental Health Nursing [Issues Ment Health Nurs] 2009 Jun; Vol. 30 (6), pp. 408-9.

21. References and Resources 5. Ward L; Innes M. Electronic medical summaries in general practice--considering the patient's contribution. The British Journal Of General Practice: The Journal Of The Royal College Of General Practitioners [Br J Gen Pract] 2003 Apr; Vol. 53 (489), pp. 293-7. 6. Krummenacher R; Simperl E; Cerizza D; Della Valle E; Nixon LJ; Foxvog D. Enabling the European Patient Summary through triplespaces. Computer Methods And Programs In Biomedicine [Comput Methods Programs Biomed] 2009 Aug; Vol. 95 (2 Suppl), pp. S33-43. Date of Electronic Publication: 2009 Apr 05. 7. Myers J; Frieden TR; Bherwani KM; Henning KJ. Ethics in public health research: privacy and public health at risk: public health confidentiality in the digital age. American Journal Of Public Health [Am J Public Health] 2008 May; Vol. 98 (5), pp. 793-801. Date of Electronic Publication: 2008 Apr 01. 8. Malin B; Nyemba S; Paulett J. Learning relational policies from electronic health record access logs. Journal Article; Research Support, N.I.H., Extramural; Research Support, U.S. Gov't, Non-P.H.S.

22. References and Resources 9. Kluge EH. Medical narratives and patient analogs: the ethical implications of electronic patient records. Methods Of Information In Medicine [Methods Inf Med] 1999 Dec; Vol. 38 (4-5), pp. 253-9. 10. Peterson D; Wickeham D. New challenge for academic psychiatry: the electronic health record. Academic Psychiatry: The Journal Of The American Association Of Directors Of Psychiatric Residency Training And The Association For Academic Psychiatry [Acad Psychiatry] 2011 Mar-Apr; Vol. 35 (2), pp. 76-80. 11. Salomon RM; Blackford JU; Rosenbloom ST; Seidel S; Clayton EW; Dilts DM; Finder SG. Openness of patients' reporting with use of electronic records: psychiatric clinicians' views. Journal Of The American Medical Informatics Association: JAMIA [J Am Med Inform Assoc] 2010 Jan-Feb; Vol. 17 (1), pp. 54-60. 12. Quinlan KJ. Patient privacy in a digital world. Behavioral Healthcare [Behav Healthc] 2008 Jun; Vol. 28 (6), pp. 32, 34. 13. Fetter MS. Personal health records: protecting behavioral health consumers' rights. Issues In Mental Health Nursing [Issues Ment Health Nurs] 2009 Nov; Vol. 30 (11), pp. 720-2.

23. References and Resources 14. Satkoske VB; Parker LS. Practicing preventive ethics, protecting patients: challenges of the electronic health record. The Journal Of Clinical Ethics [J Clin Ethics] 2010 Spring; Vol. 21 (1), pp. 36-8. 15. Powell J; Fitton R; Fitton C. Sharing electronic health records: the patient view. Informatics In Primary Care [Inform Prim Care] 2006; Vol. 14 (1), pp. 55-7. 16. Nicholas JR. Sharing summary care records. Same risks whichever way. BMJ (Clinical Research Ed.) [BMJ] 2010 Aug 10; Vol. 341, pp. c4304. Date of Electronic Publication: 2010 Aug 10. 17. Loukides G; Denny JC; Malin B. The disclosure of diagnosis codes can breach research participants' privacy. Journal Of The American Medical Informatics Association: JAMIA [J Am Med Inform Assoc] 2010 May-Jun; Vol. 17 (3), pp. 322-7.

24. References and Resources 18. Rothstein MA. The Hippocratic bargain and health information technology. The Journal Of Law, Medicine & Ethics: A Journal Of The American Society Of Law, Medicine & Ethics [J Law Med Ethics] 2010 Spring; Vol. 38 (1), pp. 7-13. 19. Vesely R. The search is on. Data privacy remains a top concern as Google seeks more users partners for its new personal health-record platform. Modern Healthcare [Mod Healthc] 2008 Sep 29; Vol. 38 (39), pp. 24-6. 20. Robertson MD; Kerridge IH. "Through a glass, darkly": the clinical and ethical implications of Munchausen syndrome. The Medical Journal Of Australia [Med J Aust] 2009 Aug 17; Vol. 191 (4), pp. 217-9.

25. Questions?

26. Contact Information: Susan D. Wiley, MD Susan.Wiley@LVHN.ORG Gail Stern, MSN, PMHCNS-BC Gail.Stern@LVHN.ORG Jamie Bongiovi, LCSW Jamie.Bongiovi@LVHN.ORG

27. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!