Psych secrecy

Adam Kaplin's multiple sclerosis patients hope for less pain, increased energy, an end to depression. Fulfilling that hope requires the coordinated effort of primary care physicians, psychiatrists, physical therapists, and other health care specialists. But Kaplin, who serves as the chief psychiatric consultant to the Johns Hopkins Multiple Sclerosis and Transverse Myelitis centers, kept encountering a problem. "I had colleagues in other Johns Hopkins outpatient clinics who said, 'We'd like to see your patient reports, but we can't see what you did. We can't follow along,'" says Kaplin. The problem was that unlike other patient records, his reports were outpatient psychiatric reports, and therefore not accessible.

Kaplin suspected that keeping psych records private could adversely affect his patients' health, and his latest study confirms it. Analyzing publicly available discharge data from 13 of the top 18 U.S. hospitals as ranked by U.S. News & World Report in 2007, Kaplin found that within a month of discharge psychiatric patients were 40 percent less likely to require readmission to the hospital if other specialists had full access to their psychiatric electronic patient records. The implication, says Kaplin, is that patients have better outcomes when psychiatrists engage in collaborative care and hospital systems make it easy to share patient records. Yet fewer than half of the top 18 hospitals kept all psychiatric records stored electronically, and less than one-quarter allowed non-psychiatrists unrestricted access to them.

Why the secrecy? Three-quarters of the hospitals in his study that did not share psychiatric information maintained electronic records. So the barrier to sharing information was not insufficient technology or cost or ease of data transmission. Rather, it was all about stigma, says Kaplin, the belief that patients could be stigmatized if other doctors know they have psychiatric illnesses.

At Johns Hopkins, Kaplin found "there was just a misunderstanding where they believed that psychiatric records were verboten to be put into shared records." Some colleagues even told him that physicians sharing psychiatric information was a form of medical malpractice, although there is nothing inherently—or legally— different between psychiatric or non-psychiatric patient confidentiality. Prior to 2009, Johns Hopkins physicians shared limited information via a computerized provider order entry system; detailed patient records were kept on paper or, at the individual physician's discretion, stored electronically on a separate system. Accessing the detailed records, particularly mental health records such as those for Kaplin's psychiatric consults with MS patients, "was very tough," says clinical informatics project coordinator Kimberly Coursen-Antinone.

Hospitals do their patients a twofold disservice by keeping psychiatric records private, or treating them as somehow different from other patient records, says Kaplin. First, problems arise when a psychiatric patient follows up with a primary care physician who, without access to hospital records, does not know which psychiatric medications to keep him on. Or, if the discharged patient ends up in the emergency department, the ED staff, without access to hospital records, can't compare the patient's present distress with his medical history. When they don't know whether he has improved or declined since his previous hospital stay, "they're more likely to assume the patient needs to go back into the hospital," says Kaplin.

Second, a patient's physical health can be at risk when psychiatric information isn't shared. Psychiatric drugs can interact adversely with other medications prescribed by unknowing physicians. Other information can be critical as well. For example, patients who have suffered heart attacks are more likely to die within a year if they also suffer from depression; the risk factor is just as large as that of hypertension, high cholesterol, or smoking. If a psychiatrist and cardiologist share patient records, the information could save patients' lives.

At Johns Hopkins, psychiatry was the first department on the East Baltimore campus to digitize its inpatient records—and share them with other Hopkins physicians—when the electronic patient record system made its debut in 2009. And all psychiatric patient records, whether inpatient or outpatient, will get the same treatment when a new digital system, called Epic, goes live in spring 2013. It's a great example of how psychiatrists can lead the way toward destigmatizing mental health conditions, says Kaplin. "If we [psychiatrists] handle the diagnosis as somehow different from HIV or STDs or other medical conditions, if we make no effort to entrust this information to other clinicians, how do we expect them not to judge our patients?" he says. "It's important for us to start the discussion about stigma."