Several needs and constraints drive conflicting goals in maintaining psychiatric records, including patients' concerns, clinicians' recording behaviors, data accuracy and accessibility, federally-accepted special procedures for psychiatric notes, and stigma.² Time-saving benefits are controversial,^{3 4} but will improve over time along with patient safety, cost control, and other benefits.⁵ We developed a survey to evaluate mental health professionals' perceptions and beliefs regarding privacy, record quality, and data safety for psychiatric documentation using an EHR system.

Major issues relevant to the adoption of an EHR by psychiatric clinicians come from the points of view of all individuals involved and also of society as a whole. The cardinal concerns of privacy, data sensitivity, stigma, and the need for open clinical communications will be discussed here together, followed by issues regarding data quality, security and access, and potential personal impact. The survey items were specifically written to address the presently studied population.

Recently a national telephone survey (March 2009), conducted by the Harvard School of Public Health and the Kaiser Family Foundation, reported that 65% of 1238 adult respondents believed that it was somewhat or very important for doctors to use electronic medical records. However, 59% were not too confident or not at all confident that their electronic records would remain confidential, and 76% believed it would be very or somewhat likely that an unauthorized person would be able to access their medical record.⁹ This is not new: almost 10 years ago a California HealthCare Foundation report revealed that almost one-fifth of a sample of Americans believed that release of their mental health records had adversely affected them in some way.¹⁰ According to this 1999 survey, responses from 1100 Californians and 1000 other Americans showed that: “Close to half of the people affected by improper disclosure say it resulted personal embarrassment or harm. In total, 7% of all US adults and 9% of California adults say they have been personally embarrassed or harmed by a violation of their medical privacy. The segment of the population most likely to have been hurt are those who have used mental health services…”.

The perception of risks from breaches in data security may increase discomfort with seeking counseling or other psychiatric treatment; may cause patients to keep psychiatric care a secret from family, friends, other medical practitioners, or employers; and may influence accuracies and completeness of disclosures that are critical to success in psychotherapy.⁶ These concerns are not limited to consumers, but also affect the acceptance of the EHR systems by clinicians. In a survey of outpatient physicians, psychiatrists were the least likely to use EHRs (8% of psychiatrists vs 18% overall).¹¹ Understanding concerns of mental health clinicians will be critical to increasing acceptance.

Patients' and mental health providers' perceptions of psychiatric record security are affected by occasional but very high-profile reports of EHR system breaches. For example, a 2001 JAMA editorial pointed out that a privacy researcher was able to access the medical record of the then governor of Massachusetts by using an “anonymous” database of State Employee Health Insurance Claims, his town of residence and zip code, his birth date, and his gender.² The same editorial quoted a past president of the American Psychiatric Association, Daniel Borenstein, as saying, “In the internet age, some wonder if privacy exists.” It is evident to these and other observers that people who see psychiatrists must feel secure that their revelations will remain private.

A number of efforts have addressed the problem of privacy and security for EHR systems, especially for mental health records. These include federal standards demarcating the boundary between a patient's general medical record and psychotherapy notes, such as those that went into effect in April 2003 as part of HIPAA rule 45 CFR §164.501.¹³ The new standards clarify that psychotherapy notes must not be kept with the general medical record and may only be released with the written authorization of the patient. Standards for the privacy of psychotherapy notes were inspired, in part, by the landmark court case, Jaffee v Redmond in 1996. In that decision, the court suppressed a request for access, by the decedent's family, to the psychiatric record of a police officer who had shot a man involved in an altercation.^{14 15 16} In addition, numerous technical approaches have been developed to enhance privacy and security across medical records; examples include integrating disparate approaches to privacy, improving access audits, performing in-depth analyses of privacy breaches, and improving models for access controls.^{17 18 19 20 21 22 23}

At Vanderbilt Medical Center (VMC), an EHR system was developed for outpatient psychiatric records and deployed in 2003. Reasons given for the switch from paper charts included patient safety, with improved access to records in emergencies, lower costs of maintaining records, improved legibility and general convenience, and lower costs of providing responses to increasingly frequent and detailed requirements for copies of records for third-party payers. The latter is especially important in environments where frequent changes in insurance coverage are encountered. In our large medical center, where patients receive care from many different departments across a multi-facility campus, the transportation of paper charts had become unreliable and costly. The VMC EHR system was designed to assure that healthcare providers across the institution could access needed clinical records. For mental health services, all notes, appointments, and phone communications were sequestered in a separate database accessible only to psychiatric clinicians and staff. This continued the previous policy in that the paper psychiatric charts, similarly kept only in the charting rooms of each psychiatric clinic, were not available to most medical center clinicians. Internists and surgeons, for example, see no charted evidence in the EHR system that a given patient is under the care of a psychiatrist, even if seeking the record after the patient has revealed such information directly. Unless patients request that their note at a specific visit be recorded by the mental health provider in the database open to all clinicians, healthcare providers who are not established mental health providers cannot read psychiatric notes in the EHR systems. Only laboratory results, a list of diagnoses and medical problems, and the medication list are not sequestered and are currently available to all healthcare providers.

This is consistent with a 2004 study of clinicians in a medical setting, where the EHR was seen as helpful for physician–patient interactions.⁴ In our study, a shift toward documentation of less private material was noted by clinicians, while they also simultaneously replied that the EHR is more complete and yet not more factual. We may be getting more of the non-sensitive data, perhaps, without an increase in clinically important but more sensitive detail. In this regard, it may be necessary to assess whether therapeutic discussions themselves are also drifting toward a more technical, and less private, topic set.

There are several limitations. The sample size is modest, and reflects only the impressions of mental health clinicians in a single academic medical center. Larger studies inclusive of more diverse mental health clinic settings, and of other specialties in which confidentiality is a major concern (eg, obstetrics, infectious disease) are required. These data were collected in 2005, and may differ from current clinician views.

Designers of future systems will need to enhance electronic file security and simultaneously maintain legitimate accessibility in order to preserve confidence in psychiatric and other EHR systems. The ramifications of data security cover more than the psychiatric domain, implying a need for considerable reflection. The ability to satisfy privacy and confidentiality needs will be critical to greater success in implementation(s) of EHR systems.