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Psychiatrist Glen Gabbard, M.D., of the Menninger School of Psychiatry is one of those who see few advantages to the rapid computerization of medical records. He attributes much of the growing skepticism patients have about trusting the medical system to the spread of the managed care revolution.
"The essence of the doctor-patient relationship has been eroded" by the easy access third parties have to medical records, he emphasized. "Confidentiality to psychiatry is what a sterile field is to surgery," but that concept carries less and less weight with the people who process medical records and pay insurance bills.
Gabbard suggested that in light of the porousness of existing databases, he would not hesitate to caution a patient who was too worried about psychiatric treatment information leaking to coworkers to use insurance benefits that those concerns were justified. With the current state of computer safeguards, "patients have good reason to be paranoid" about their medical records finding their way into the hands of other people, he warned.
Psychiatrist and managed care executive Ronald Geraty, M.D., sees an upside, however, to having a vast trove of medical data stored electronically, though he acknowledged that there are trade-offs that accompany the advantages.
"The rapid explosion of treatment improvements made possible as a result of being able to study the data" argues in favor of the value of large, computerized databases, he said. He added that he looks forward to a time when his company--Merit Behavioral Health, of which he is executive vice president--can communicate with physicians entirely by computer and avoid the hassles of telephone communication. Merit is in the process of adding computer security checks such as encryption codes, "audit trails," and dedicated modems as solutions to the problem of confidentiality leaks traceable to electronic data storage.
Geraty did note that the sharing of confidential information, which a system of third-party payment and review necessarily entails--and the "risk that unauthorized people will dip into it"--is one of the negative attributes of the computer age.
Gabbard expressed far more alarm than Geraty, however, over the repercussions of computer leaks of medical records, characterizing them as "horror stories." He described true examples such as someone buying a used computer once owned by a pharmacy that still contained records of patients' medication use and identifying information, the clerks in the Maryland Medicaid office who sold the names and medical records of beneficiaries to four HMO's who were competing to enroll Medicaid patients, and of a banker who gained access to hospital records and, after cross-referencing them with bank records, called in the loans of borrowers being treated for cancer.
Patients' fears of confidentiality breaches have reached the point where patients now routinely withhold information valuable to their treatment, preventing their psychiatrist from delivering optimal and cost-effective care, Gabbard noted.
From the managed care industry's perspective, Gabbard's predictions of dire consequences from erosion of patient privacy and increased disclosure appear overly ominous, suggested George Wolreich, M.D.
"Confidentiality isn't an absolute, it's a plastic concept," said Wolreich, medical director for the Northeast region of Merit Behavioral Health. In addition to being a mechanism to build trust, "it can be used as a resistance, a way to get things and a way to avoid things."
He added that when a patient asks a third party to pay for his or her medical care, that party has a right to gain access to the data that describe what it's paying for. Without such oversight, "we may in fact be doing the patient a disservice medically and doing ourselves a disservice legally," said Wolreich. The legal right to have access to the complete medical record arises because the concept of agency likely applies when an insurer or review company refers a patient or has some say in the parameters of the patient's treatment, he suggested.
Confronted with the reality that third parties will continue to have access to medical records unless a patient agrees to pay for his or her own treatment, Los Angeles psychiatrist Marcia Goin, M.D., a former chair of the APA Committee on Confidentiality, has a response ready for her patients. After discussing a patient's concerns about the confidentiality limits, "I talk about what I will do in the face of these realities to protect his privacy. I would then move on to talk about what I will do to treat his illness" and prevent an outcome that could be more tragic than someone gaining unauthorized access to his records, Goin advised.
Highlighting the conflicting goals that come into play when access to medical records is at issue, Wolreich gave the example of an HMO in the southwestern U.S. that has begun routinely screening its primary care patients' records for symptoms of depression. If the intent of doing so is to allow the HMO to inform a primary care doctor that he or she has missed signs of depression, he asked, is this a good or bad use of computerized medical records, especially when it is known that about 20 percent of primary care patients suffer from depression and that it often goes untreated?
Goin responded, however, that she is "amazed" by the contention that an insurer's record review would pick up important clues missed by a treating physician. She emphasized that the likely scenario is that if the physician missed key symptoms of depression, relevant information would not then be included in the chart in the first place for reviewers to later pick up.
"If something's been missed, it's been missed," she said. But the two managed care executives insisted that this situation is a common occurrence and that this type of managed care review is thus a form of patient protection.
Acknowledging that economic self-interest does play a role in managed care companies' desire to have as much data available as possible when they review patient records, Geraty maintained that the existence of such self-interest does not preclude a "confluence" with improvement in overall treatment, as the primary care example indicates.
In response to questions from incoming APA Vice President Daniel Borenstein, M.D., who chaired the roundtable, none of the panel members was willing to agree that adequate methods now exist to ensure that the privacy of patient records will be protected, and all subscribed to the view that patients have ownership and ultimate control over their medical records.
(Psychiatric News, July 4, 1997)