At Weill Cornell Medicine where I work, regular doctors were not able to access psychiatry notes in the electronic health record (EHR). This meant primary care practitioners (PCPs) could read cardiology and oncology notes but not psychiatry notes. The only way for the PCPs to figure out what was happening with psychiatric medications, depression symptoms, panic attacks, alcohol abuse, a divorce crisis and so on, was to call the psychiatrist directly. It was possible to see the details of an inpatient admission for heart failure but impossible to see the corresponding information for a suicide attempt, exacerbation of psychosis, or anorexia.

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Source: Shutterstock_526087603

Calling the psychiatrist directly involves overcoming two main barriers, getting the patient to sign a release form and the availability of both parties in the midst of busy schedules. Because this process was too time consuming, it rarely occurred.

The major disadvantage of having your psychiatric notes accessible to other clinicians is the potential embarrassment. It might be uncomfortable to know that every clinician, from dermatology to nutrition, can access the secrets of your heart. After all, we aspire to be open and honest with our therapists. We discuss affairs, drug use, sexual abuse, spouses, kids, parents, disappointments, and so forth. Sorting out these intensely personal issues leads to growth and happiness so it pays to be frank. But who wants to air their dirty laundry for unrelated caregivers to read?

In addition, once the EHR contains your psychiatric notes, they are there forever. Insurance companies can request copies for billing compliance. Lawyers litigating on your behalf often request copies of the medical chart in its entirety. In theory, however, all people with access to personal health information are duty bound to preserve confidentiality.

The advantages of documenting psychiatric notes in the EHR, nevertheless, are enormous in view of recent collaborative care psychiatry research. This shows that people who have co-morbid psychiatric and medical problems have worse medical outcomes. However, treating the psychiatric problem can lead to better medical outcomes.

For example, if you have diabetes and are depressed, then you are more likely to eat the wrong food, skip medication doses, not exercise, and to keep smoking and drinking. You are, therefore, more likely to end up in the emergency department with complications of your diabetes such as foot infections. Over time medical complications recur and accumulate leading to amputations of toes, heart disease, stroke, and blindness. Treating the depression is an essential part of getting diabetes under control.

For this reason, depression screening is now considered an important part of PCP’s work. The PCP is seen as the gatekeeper of your wellness and a vital part of this work is coordinating your care through a network of specialists.

When we changed this paradigm by allowing PCPs to see our Collaborative Care Psychiatric notes at Weil Cornell, we received resounding positive survey feedback. The PCPs were delighted to share the psychiatrist’s treatment strategies and the improved patient outcomes spoke for themselves.

Not all the Weill Cornell psychiatrists, however, liked this model or agreed to adopt it. The reason is that it requires a different approach to documenting psychiatric notes.

The note has to briefer with an acute sensitivity to causing embarrassment to the patient. Not every detail from the session needs to go into the note. Often just a sentence is enough. For example, “Today we worked on reframing distorted cognitions relating to self-esteem and negating positive achievements.” There is no place for ponderous psycho-analytic notes that were not meant for eyes other than the therapist's. These are easily misconstrued. 

Because a "warm handover" is an integral part of Collaborative Care Psychiatry, notes are often accompanied by a secure email, to the PCP outlining progress or changes in medication rather than a phone call. In this way, technology embedded into the EHR is used to overcome communication barriers and ensure that everyone is on the same page.

So the answer to the question, “Should your PCP read your psychiatrist’s notes?” is a resounding "yes!" There is clear research indicating that improved mental health drives physical wellbeing. Shared psychiatric-medical EHR notes are an important foundation stone for the Collaborative Care movement.

Nevertheless, patients should now have a conversation with their psychiatrist or psychologist about what is and is not documented in the EHR. You should also ask who can access your chart.

Many hospitals use software that prevents unauthorized access to your chart by clinicians not involved in your care. Unauthorized access can lead to being fired. Ask about what electronic protections are in place. Some EHRs also allow the medical note to be shared with the patient, based on the notion that it is a patient’s right to access their own medical data. You can read your own psychiatric note to get a sense of what is being shared. Super secret notes can be kept in a special electronic folder that only the psychiatrist can access and this offers another level of protection.

Finally, it is also important to continue to be frank with your therapist and your PCP, because, regardless of the technology, trust is central to healing.

References

Stewart, J.C., Perkins, A.J., Callahan, C.M. (2014). Effect of collaborative care for depression on risk of cardiovascular events: data from the IMPACT randomized controlled trial. Psychosom Med. 76(1):29-37

About the Author

Tomer T Levin M.D.

Tomer T. Levin, M.D. is a collaborative care psychiatrist and CBT therapist at Weil Cornell Medicine/New York Presbyterian who helps with psychological and physical wellness.

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