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January 1, 2006
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Confidentiality and care coordination issues affect how behavioral healthcare interfaces with primary care in an electronic medical record

Behavioral healthcare documentation in electronic medical records (EMRs) poses both challenges as well as opportunities to integrate behavioral healthcare with the overall healthcare delivery system. EMRs offer the ability to provide timely behavioral healthcare information to primary and specialty care physicians that can enhance care coordination. Yet a primary concern is addressing the importance of confidentiality.

This article focuses on two areas. First, we examine the fundamental issues healthcare providers and leaders should consider in determining how behavioral healthcare documentation should be integrated into EMRs. Second, we consider potential strategies to address these issues. Our experience is based on Group Health Cooperative's two-year implementation of an EMR system. Group Health Cooperative is an integrated healthcare system serving nearly 550,000 people in Washington State and Idaho.

Fundamental Issues

The core issue in determining how behavioral healthcare documentation is integrated within the overall EMR is addressing the direction of a healthcare organization as it pertains to balancing the importance of care coordination and confidentiality. Key questions to consider are:

What has been your organization's expe-rience with sharing behavioral healthcare documentation with primary care/specialty care?

How an organization historically has addressed confidentiality/care coordination issues within a paper record system will have a significant influence on how to address these issues within an EMR. Relevant issues include the number of patient complaints regarding specially protected healthcare information (e.g., mental healthcare and chemical dependency) being included in a medical chart, as well as any quality-of-care concerns that have been the result of primary/specialty care providers not being able to have access to behavioral healthcare information.

What is your organization's strategic di-rection regarding the integration of behavioral healthcare and your healthcare delivery system?

If your organization has had a number of strategic initiatives focused on integrating behavioral healthcare into your healthcare delivery system (e.g., depression management in primary care), then it is important that your behavioral healthcare documentation in an EMR be relatively highly integrated within your healthcare system, and that the content is relevant to a broader audience than just behavioral healthcare clinicians.

What are key constituents’ perspectives on confidentiality/care coordination regarding behavioral healthcare documentation within a healthcare system?

Through either focus groups or surveys, determine the perspectives of primary/specialty healthcare providers, behavioral healthcare providers, and patients regarding the inclusion of behavioral healthcare documentation within the overall medical record.

What is the status of behavioral healthcare documentation standards before the EMR implementation?

An EMR increases documentation visibility among various behavioral healthcare providers and primary/specialty healthcare providers. How well the information has been documented in paper records by various behavioral healthcare providers, as well as how that information is shared with primary care providers, will indicate how much leadership direction is needed to develop consistent documentation approaches integral to an EMR.

What is the EMR you are using, or considering, capable of?

EMRs are typically designed for universal sharing among all clinicians. Most EMRs have not been structured to address issues associated with both confidentiality and coordination of care in behavioral health documentation. Your organization will need to address the level of technical support available within your delivery system or with the EMR vendor to do the customization often necessary for behavioral health documentation.

When Group Health reviewed these issues, we found strong interest in both preserving confidentiality and ensuring that information is available to healthcare providers to assist with coordination-of-care issues. We found:

  • A strong interest in promoting care coordination between primary care and behavioral healthcare. Primary care doctors had been concerned that they historically had not received enough information regarding behavioral healthcare patients. A number of strategic initiatives had been undertaken to integrate behavioral healthcare with the overall healthcare system.

  • Consumers felt it was important for their primary care physicians to be aware of basic information regarding their behavioral healthcare, as well as to preserve the confidentiality of behavioral healthcare documentation. Consumers wanted more personal information to stay within the behavioral healthcare system.

  • Behavioral healthcare providers shared similar concerns about the impact of broader sharing of information on the therapeutic relationship. Group Health historically had a separate behavioral healthcare chart with limited information available to the overall healthcare system.

TABLE. Group Health's split-note EMR structure for mental healthcare documentation*


Assessment and Plan (A/P)

Subjective and Objective (S/O)

*This practice is consistent with HIPAA guidelines that pertain to protected healthcare information, as well as state of Washington regulations (RCW.71) regarding the confidentiality of mental healthcare, for which both indicate that medically necessary information can be shared with other healthcare providers when there is a clinical need to know.