Clinical documentation of patient identities in the electronic health record: Ethical principles to consider

Decker, S. E., et al. (2023). 

Psychological Services.

Advance online publication.

https://doi.org/10.1037/ser0000816

Abstract

The American Psychological Association’s multicultural guidelines encourage psychologists to use language sensitive to the lived experiences of the individuals they serve. In organized care settings, psychologists have important decisions to make about the language they use in the electronic health record (EHR), which may be accessible to both the patient and other health care providers. Language about patient identities (including but not limited to race, ethnicity, gender, and sexual orientation) is especially important, but little guidance exists for psychologists on how and when to document these identities in the EHR. Moreover, organizational mandates, patient preferences, fluid identities, and shifting language may suggest different documentation approaches, posing ethical dilemmas for psychologists to navigate. In this article, we review the purposes of documentation in organized care settings, review how each of the five American Psychological Association Code of Ethics’ General Principles relates to identity language in EHR documentation, and propose a set of questions for psychologists to ask themselves and their patients when making choices about documenting identity variables in the EHR.

Impact Statement

Psychologists in organized care settings may face ethical dilemmas about what language to use when documenting patient identities (race, ethnicity, gender, sexual orientation, and so on) in the electronic health record. This article provides a framework for considering how to navigate these decisions based on the American Psychological Association Code of Ethics’ five General Principles. To guide psychologists in decision making, questions to ask self and patient are included, as well as suggestions for further study.

Here is my summary:

The authors emphasize the lack of clear guidelines for psychologists on how and when to document these identity variables in EHRs. They acknowledge the complexities arising from organizational mandates, patient preferences, fluid identities, and evolving language, which can lead to ethical dilemmas for psychologists.

To address these challenges, the article proposes a framework based on the five General Principles of the American Psychological Association (APA) Code of Ethics:

1. Fidelity and Responsibility: Psychologists must prioritize patient welfare and act in their best interests. This includes respecting their privacy and self-determination when documenting identity variables.
2. Competence: Psychologists should possess the necessary knowledge and skills to accurately and sensitively document patient identities. This may involve ongoing training and staying abreast of evolving language and cultural norms.
3. Integrity: Psychologists must maintain ethical standards and avoid misrepresenting or misusing patient identity information. This includes being transparent about the purposes of documentation and seeking patient consent when appropriate.
4. Respect for Human Rights and Dignity: Psychologists must respect the inherent dignity and worth of all individuals, regardless of their identity. This includes avoiding discriminatory or stigmatizing language in EHR documentation.
5. Social Justice and Public Interest: Psychologists should contribute to the promotion of social justice and the elimination of discrimination. This includes being mindful of how identity documentation can impact patients' access to care and their overall well-being.

To aid psychologists in making informed decisions about identity documentation, the authors propose a set of questions to consider:

1. What is the purpose of documenting this identity variable?
2. Is this information necessary for providing appropriate care or fulfilling legal/regulatory requirements?
3. How will this information be used?
4. What are the potential risks and benefits of documenting this information?
5. What are the patient's preferences regarding the documentation of their identity?

By carefully considering these questions, psychologists can make ethically sound decisions that protect patient privacy and promote their well-being.

Doctors are drowning in paperwork. Some companies claim AI can help

Geoff Brumfiel

NPR.org - Health Shots

Originally posted 5 APR 23

Here are two excerpts:

But Paul kept getting pinged from younger doctors and medical students. They were using ChatGPT, and saying it was pretty good at answering clinical questions. Then the users of his software started asking about it.

In general, doctors should not be using ChatGPT by itself to practice medicine, warns Marc Succi, a doctor at Massachusetts General Hospital who has conducted evaluations of how the chatbot performs at diagnosing patients. When presented with hypothetical cases, he says, ChatGPT could produce a correct diagnosis accurately at close to the level of a third- or fourth-year medical student. Still, he adds, the program can also hallucinate findings and fabricate sources.

"I would express considerable caution using this in a clinical scenario for any reason, at the current stage," he says.

But Paul believed the underlying technology can be turned into a powerful engine for medicine. Paul and his colleagues have created a program called "Glass AI" based off of ChatGPT. A doctor tells the Glass AI chatbot about a patient, and it can suggest a list of possible diagnoses and a treatment plan. Rather than working from the raw ChatGPT information base, the Glass AI system uses a virtual medical textbook written by humans as its main source of facts – something Paul says makes the system safer and more reliable.

(cut)

Nabla, which he co-founded, is now testing a system that can, in real time, listen to a conversation between a doctor and a patient and provide a summary of what the two said to one another. Doctors inform their patients that the system is being used in advance, and as a privacy measure, it doesn't actually record the conversation.

"It shows a report, and then the doctor will validate with one click, and 99% of the time it's right and it works," he says.

The summary can be uploaded to a hospital records system, saving the doctor valuable time.

Other companies are pursuing a similar approach. In late March, Nuance Communications, a subsidiary of Microsoft, announced that it would be rolling out its own AI service designed to streamline note-taking using the latest version of ChatGPT, GPT-4. The company says it will showcase its software later this month.

The info is here.

Do You Really Want to Read What Your Doctor Writes About You?

Zoya Qureshi

The Atlantic

Originally posted 15 NOV 22

You may not be aware of this, but you can read everything that your doctor writes about you. Go to your patient portal online, click around until you land on notes from your past visits, and read away. This is a recent development, and a big one. Previously, you always had the right to request your medical record from your care providers—an often expensive and sometimes fruitless process—but in April 2021, a new federal rule went into effect, mandating that patients have the legal right to freely and electronically access most kinds of notes written about them by their doctors.

If you’ve never heard of “open notes,” as this new law is informally called, you’re not the only one. Doctors say that the majority of their patients have no clue. (This certainly has been the case for all of the friends and family I’ve asked.) If you do know about the law, you likely know a lot about it. That’s typically because you’re a doctor—one who now has to navigate a new era of transparency in medicine—or you’re someone who knows a doctor, or you’re a patient who has become intricately familiar with this country’s health system for one reason or another.

When open notes went into effect, the change was lauded by advocates as part of a greater push toward patient autonomy and away from medical gatekeeping. Previously, hospitals could charge up to hundreds of dollars to release records, if they released them at all. Many doctors, meanwhile, have been far from thrilled about open notes. They’ve argued that this rule will introduce more challenges than benefits for both patients and themselves. At worst, some have fretted, the law will damage people’s trust of doctors and make everyone’s lives worse.

A year and a half in, however, open notes don’t seem to have done too much of anything. So far, they have neither revolutionized patient care nor sunk America’s medical establishment. Instead, doctors say, open notes have barely shifted the clinical experience at all. Few individual practitioners have been advertising the change, and few patients are seeking it out on their own. We’ve been left with a partially implemented system and a big unresolved question: How much, really, should you want to read what your doctor is writing about you?

(cut)

Open notes are only part of this conversation. The new law also requires that test results be made immediately available to patients, meaning that patients might see their health information before their physician does. Although this is fine for the majority of tests, problems arise when results are harbingers of more complex, or just bad, news. Doctors I spoke with shared that some of their patients have suffered trauma from learning about their melanoma or pancreatic cancer or their child’s leukemia from an electronic message in the middle of the night, with no doctor to call and talk through the seriousness of that result with. This was the case for Tara Daniels, a digital-marketing consultant who lives near Boston. She’s had leukemia three times, and learned about the third via a late-night notification from her patient portal. Daniels appreciates the convenience of open notes, which help her keep track of her interactions with various doctors. But, she told me, when it comes to instant results, “I still hold a lot of resentment over the fact that I found out from test results, that I had to figure it out myself, before my doctor was able to tell me.”

The info is here.

Empathy in the Age of the EMR

Danielle Ofri
The Lancet

Here is an excerpt:

Keeping the doctor-patient connection from eroding in the age of the EMR is an uphill battle. We all know that the eye contact that Fildes depicts is a critical ingredient for communication and connection, but when the computer screen is so demanding of focus that the patient becomes a distraction, even an impediment—this is hopelessly elusive.

Recently, I was battling the EMR during a visit with a patient who had particularly complicated medical conditions. We hadn’t seen each other in more than a year, so there was much to catch up on. Each time she raised an issue, I turned to the computer to complete the requisite documentation for that concern. In that pause, however, my patient intuited a natural turn of conversation. Thinking that it was now her turn to talk, she would bring up the next thing on her mind. But of course I wasn’t finished with the last thing, so I would say, “Would you mind holding that thought for a second? I just need to finish this one thing…”

I’d turn back to the computer and fall silent to finish documenting. After a polite minute, she would apparently sense that it was again her turn in the conversation and thus begin her next thought. I was torn because I didn’t want to stop her in her tracks, but we’ve been so admonished about the risks inherent in distracted multitasking that I wanted to focus fully on the thought I was entering into the computer. I know it’s rude to cut someone off, but preserving a clinical train of thought is crucial for avoiding medical error.

The info is here.

Document ‘informed refusal’ just as you would informed consent

James Scibilia
AAP News
Originally posted October 20, 2018

Here is an excerpt:

The requirements of informed refusal are the same as informed consent. Providers must explain:

• the proposed treatment or testing;
• the risks and benefits of refusal;
• anticipated outcome with and without treatment; and
• alternative therapies, if available.

Documentation of this discussion, including all four components, in the medical record is critical to mounting a successful defense from a claim that you failed to warn about the consequences of refusing care.

Since state laws vary, it is good practice to check with your malpractice carrier about preferred risk management documentation. Generally, the facts of these discussions should be included and signed by the caretaker. This conversation and documentation should not be delegated to other members of the health care team. At least one state has affirmed through a Supreme Court decision that informed consent must be obtained by the provider performing the procedure and not another team member; it is likely the concept of informed refusal would bear the same requirements.

The info is here.

Changing the way we communicate about patients

Abraar Karan
BMJ Blog
Originally posted August 29, 2018

Here is an excerpt:

There are many changes that we can make to improve how we communicate about patients. One of the easiest and most critical transformations is how we write our medical notes. One of the best doctors I ever worked with did exactly this, and is famous at the Brigham (our hospital) for doing it. He systematically starts every single note with the person’s social history. Who is this patient? It is not just a lady with abdominal pain. It is a mother of three, a retired teacher, and an active cyclist. That is the first thing we read about her, and so when I enter her room, I can’t help but see her this way rather than as a case of appendicitis.

This matters because patients deserve to be treated as people—a statement that’s so obvious it shouldn’t need to be said, but which physician behaviour doesn’t always reflect. You wouldn’t expect to know the most sensitive and vulnerable aspects of someone before even knowing their most basic background, yet we do this in medicine all the time. This is also important because in many clinical presentations, it provides critical information that helps deduce how they got sick, and why they may get sick again in the same way if we don’t restructure something essential in their life. For instance, if I didn’t know that the 22 year old opioid addict had just been kicked out of his house and is on the street without transportation to get to his suboxone clinic, I will not have truly solved what brought him to the hospital in the first place.

The info is here.

The map is not the territory: medical records and 21st century practice

Stephen A Martin & Christine A Sinsky
The Lancet
Published: 25 April 2016

Summary

Documentation of care is at risk of overtaking the delivery of care in terms of time, clinician focus, and perceived importance. The medical record as currently used for documentation contributes to increased cognitive workload, strained clinician–patient relationships, and burnout. We posit that a near verbatim transcript of the clinical encounter is neither feasible nor desirable, and that attempts to produce this exact recording are harmful to patients, clinicians, and the health system. In this Viewpoint, we focus on the alternative constructions of the medical record to bring them back to their primary purpose—to aid cognition, communicate, create a succinct account of care, and support longitudinal comprehensive care—thereby to support the building of relationships and medical decision making while decreasing workload.

Here are two excerpts:

While our vantage point is American, documentation guidelines are part of a global tapestry of what has been termed technogovernance, a bureaucratic model in which professionals' behaviour is shaped and manipulated by tight regulatory policies.

(cut)

In 1931, the scientist Alfred Korzybski introduced the phrase "the map is not the territory", to suggest that the representation of reality is not reality itself. In health care, creating the map (ie, the clinical record) can take on more importance and consume more resources than providing care itself. Indeed, more time may be spent documenting care than delivering care. In addition, fee-for-service payment arrangements pay for the map (the medical note), not the territory (the actual care). Readers of contemporary electronic notes, composed generously of auto-text output, copy forward text, and boiler plate statements for compliance, billing, and performance measurement understand all too well the gap between the map and the territory, and more profoundly, between what is done to patients in service of creating the map and what patients actually need.

Contemporary medical records are used for purposes that extend beyond supporting patient and caregiver. Records are used in quality evaluations, practitioner monitoring, practice certifications, billing justification, audit defence, disability determinations, health insurance risk assessments, legal actions, and research.

The article is here.

Engaging Patients Through OpenNotes: An Evaluation Using Mixed Methods

Tobias Esch, Roanne Mejilla1, M. Anselmo1, B. Podtschaske, T. Delbanco, J. Walker
BMJ Open, published online Jan. 29, 2016.

Abstract

Objectives 

(A) To gain insights into the experiences of patients invited to view their doctors’ visit notes, with a focus on those who review multiple notes;

(B) to examine the relationships among fully transparent electronic medical records and quality of care, the patient-doctor relationship, patient engagement, self-care, self-management skills and clinical outcomes.

(cut)

Results 

Patient experiences indicate improved understanding (of health information), better relationships (with doctors), better quality (adherence and compliance; keeping track) and improved self-care (patient-centredness, empowerment). Patients want more doctors to offer access to their notes, and some wish to contribute to their generation. Those patients with repeated experience reviewing notes express fewer concerns and more perceived benefits.

Conclusions 

As the use of fully transparent medical records spreads, it is important to gain a deeper understanding of possible benefits or harms, and to characterise target populations that may require varying modes of delivery. Patient desires for expansion of this practice extend to specialty care and settings beyond the physician's office. Patients are also interested in becoming involved actively in the generation of their medical records. The OpenNotes movement may increase patient activation and engagement in important ways.

The article is here.

Medical Necessity and Unnecessary Care

By Paul Keckley
The Health Care Blog
Originally posted January 29, 2015

Unnecessary care that’s not evidence-based—usually associated with excess testing, surgical procedures or over-prescribing—accounts for up to 30% of what is spent in healthcare. In recent months, enforcement actions against physicians and hospitals have gained increased attention. But unnecessary care and over-utilization is not a new story or one that’s easy to understand.

(cut)

What does it mean?

Documentation is key. Accurate clinical documentation across sites and systems of care is table stakes.

Transparency about medical necessity and unnecessary care is assured. Data about the performance of every practitioner, hospital, and health system will be widely accessible.

The entire blog post is here.

Clinical supervision of psychotherapy: essential ethics issues for supervisors and supervisees

By Jeffrey E. Barnett and Corey H. Molzon
J Clin Psychol 2014 Nov 14;70(11):1051-61. Epub 2014 Sep 14.

Abstract

Clinical supervision is an essential aspect of every mental health professional's training. The importance of ensuring that supervision is provided competently, ethically, and legally is explained. The elements of the ethical practice of supervision are described and explained. Specific issues addressed include informed consent and the supervision contract, supervisor and supervisee competence, attention to issues of diversity and multicultural competence, boundaries and multiple relationships in the supervision relationship, documentation and record keeping by both supervisor and supervisee, evaluation and feedback, self-care and the ongoing promotion of wellness, emergency coverage, and the ending of the supervision relationship. Additionally, the role of clinical supervisor as mentor, professional role model, and gatekeeper for the profession are discussed. Specific recommendations are provided for ethically and effectively conducting the supervision relationship and for addressing commonly arising dilemmas that supervisors and supervisees may confront.

The entire article is here.

Episode 14: Ethics and Quality Enhancement Strategies

In Episode 14, John welcomes Dr. Sam Knapp back to the podcast.  Sam was fresh off his Lifetime Achievement Award in Ethics Education from the American Psychological Association.  After John's first attempt at listener mail, the topic moves toward ethics education and ways to contemplate positive ethics.  Rather than looking at remedial ethics or the ethical floor, John and Sam give examples about striving for the ethical ceiling.  The focus on quality enhancement strategies grew out of risk management strategies.  From a quality enhancement perspective, Sam and John give several examples of what may trigger the need for quality enhancement strategies.  They also review four quality enhancement strategies: 1) consultation, 2) empowered collaboration, 3) documentation, and 4) redundant protections.  Sam and John also talk about psychologists' emotional reactions to patients.

At the end of this podcast, the listener will be able to:

1. Outline three quality enhancement strategies,
2. Describe how to prepare for a helpful consultation, and,
3. List the reasons why redundant protections are helpful in clinical practice.

Click here to earn one APA-approved CE credit

Find this podcast on iTunes

Or listen directly below

Resources for this podcast

Ethical Issues With Patients at a High Risk for Treatment Failure 

Samuel J. Knapp and John Gavazzi

Can Checklists Help to Reduce Treatment Failure?

Sam Knapp and John Gavazzi

Quality Enhancement Strategies - PowerPoint

John Gavazzi, PsyD ABPP

Episode 8: The Dark Side of Ethics - False Risk Management Strategies 

Therapists' Anger, Hate, Fear, and Sexual Feelings: National Survey of Therapist Responses, Client Characteristics, Critical Events, Formal Complaints, and Training

Ken Pope and Barbara G. Tabachnick

Doctors Are Talking: EHRs Destroy the Patient Encounter

By Neil Chesanow
MedScape
Originally published May 22, 2014

There's no doubt that electronic health records (EHRs) spark strong emotions in doctors -- and many of those emotions are negative.

The gripes cover three main areas: One, EHRs have made the patient encounter far more annoying and complex than it ever was before.

Two, many physicians feel that EHRs take doctors who were trained to be independent thinkers and constrain their ability to make independent decisions, causing them to feel like data entry clerks, with a computer telling them how to practice medicine.

Last but not least, a large number of physicians feel that EHRs erode the doctor-patient relationship by creating a barrier between the two.

This article, and several others, about EHRS are here.

State reprimands psychologist David T. Bice over "touch"

Psychiatric Crimes Database
Originally posted January 3, 2012

On October 8, 2012, the Oregon Board of Psychologist Examiners reprimanded David T. Bice, Ph.D. for unprofessional conduct; failure to avoid harm; failure to obtain informed consent and exceeding the boundaries of competence with regard to a teenage female patient.

According to the Board’s document, Bice engaged in “comforting touch” with the patient, which made her uncomfortable to the extent that “she will never see a male counselor again.” Bice additionally failed to make entries in the patient’s chart when he touched her, the rationale for touching, how the patient reacted, etc.; failed to get the patient’s full informed consent, relative to the use of touch in that the did not address the use of touch with the patient nor did he address it in his informed consent documents or the patient’s chart notes; exceeding the boundaries of competence by engaging in touch with the patient “without first establishing a strong therapeutic alliance and [failing] to monitor [the patient’s] reactions…and to make a corresponding chart note.”

In addition to the reprimand, Bice must successfully complete coursework in the areas of informed consent, patient charting and the use of touch during therapy and is also required to practice for a minimum of one year under the supervision of a licensed psychologist, among other things.