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The state’s social work and psychological associations are questioning the need to include private behavioral health information on the state’s Health Information Exchange, and raising concerns about potential breaches of confidentiality and the lack of clarity over who will given access to the information.
Medical providers are in the process of complying with a state law, passed in 2017, that required hospitals to provide access to their patient records by May 2022, connecting to the state’s online exchange, known as Connie, and all other medical providers by May 2023
But Steven Wanczyk-Karp, director of the Connecticut chapter of the National Association of Social Workers, told CT Examiner that behavioral health providers felt that providing data to the Connie system conflicted with their profession’s code of ethics.
“Confidentiality is something that our profession makes as a core principle,” said Wanczyk-Karp. “Even just turning over your client list, in our opinion, is a breach of confidentiality.”
To date, nearly every large hospital system in the state, including Yale New Haven Health, Hartford Healthcare, Trinity Health, UConn Health and Nuvance Health, have at least begun the process of signing on, and the Office of Health Strategy, the agency responsible for Connie, has been contacting behavioral health providers to remind them of the requirement to
Dr. Deirdre Gifford, executive director of the Office of Health Strategy, said at a press conference in January that the state was particularly focusing on information sharing for long-term care and behavioral health care. For behavioral health providers, she said, it was important for them to have access to medical records given that physical and mental health conditions can impact one another.
One licensed clinical social worker who spoke to CT Examiner on the condition of confidentiality said she was left “apoplectic” by a December call with officials about the exchange, particularly the idea that healthcare providers would have to provide patient lists to the exchange.
“That’s not acceptable. That, in it of itself, was a violation,” she said. “I as a provider am not supposed to identify someone as a client.”
Protecting Sensitive Information
Sumit Sajnani, the health information technology Officer for the Office of Health Strategy and a member of the Board of Directors for Connie, told CT Examiner that he understood the behavioral health providers’ objections. He said that Connie was looking only for specific information — in particular medications, notes on a patient’s progress and the codes that insurance companies use to categorize a patient’s diagnosis.
He said they did not require behavioral health professionals to upload psychotherapy notes, which contain more detail about a patient’s condition.
But psychologists and social workers were not convinced that this was significant protection of patients’ confidential information.
Gina Abbott, a clinical psychologist and professor of psychology at Quinnipiac University, told CT Examiner that even diagnosis codes – like PTSD or substance use — might not be information a patient wants shared. She also said that progress notes might contain sensitive information — she gave the example of a young woman who was sexually assaulted, for whom “progress” might be having consensual sex with a partner.
Abbott said her main concern was about the insurance companies having access to detailed information. She said that while she provides insurers with things like diagnostic codes and treatment summaries, there are other things she won’t share without a patient’s consent.
Abbott said she was also worried about the fact that the exchange would be sharing information across state lines, and what that would mean for information about a woman’s reproductive health.
“I am very much a defender of women’s rights and I’m really concerned — If I’m seeing a college student and she has talked to me about an unplanned pregnancy or taking plan B, or I’ve written anything in my notes indicating anything like that, and then she’s seen by a doctor in Texas — I don’t know what that means,” said Abbott.
Last year, Connecticut passed a law aimed at strengthening protections around reproductive health information. But Jenn Searls, the executive director of Connie, told CT Examiner in an email that this law does not require health providers to ask for consent before sharing that information with the exchange.
“Perhaps our concerns are being heard?”
Marcy Russo, legislative committee chair for the Connecticut Psychological Association, said that part of the problem is that it’s not clear what pieces of information would be uploaded and shared on the exchange. Meghan Butler, the association’s executive director, said the association had met with the Office of Healthcare Strategy to discuss the exchange.
Butler said that psychologists are a diverse group — some psychologists work in hospitals or private practice, while others work in college counseling centers or in forensics. She said that, depending on their practice, they may have to adhere to different laws and guidelines around privacy that need to be taken into account.
Kim Martone, chief of staff at the Office of Health Strategy, told CT Examiner that the agency was in the process of developing guidelines for behavioral health providers. But she said in an email that records about substance use, as well as other “sensitive health information” that is not covered under HIPAA would not be put into the exchange without a patient’s affirmative consent. Connecticut law also considers information about HIV/AIDS, genetic testing and mental health treatment to be “sensitive health information” that requires a patient to actively consent for it to be shared.
Social workers who spoke with CT Examiner said they found this response reassuring, but that it did not match what they had initially heard from Connie.
“Perhaps our concerns are being heard?” Wanczyk-Karp wrote in an email.
Searls said that it would be up to the mental health providers to figure out what information they needed patient consent to share.
“Every participating organization needs to make the determination of whether they capture sensitive health information and must obtain patient consent when required before sharing data through Connie,” Searls wrote in an email to Connie.
Connecticut law says that social workers, psychiatrists and psychologists are allowed to disclose records to other medical professionals without consent if they determine that the information is “needed to accomplish the objectives of diagnosis of treatment.” Under the law, the behavioral health provider has to inform the patient that their records are being released.
Searls said during a Webinar for behavioral health providers earlier this month that Connie would not usurp any existing laws or regulations for behavioral health providers.
“If you are supposed to get consent before you share this data, you need to get consent before you share this data,” Searls said.
“Is it really necessary?”
Despite their concerns, psychologists and social workers did say they saw the value of having the exchange. Butler said the exchange could give behavioral health providers a greater role in caring for things like chronic pain — diagnoses that previously have been relegated to the medical realm.
Abbott said she could see the advantage, in an Emergency Room setting, of doctor’s having access to certain behavioral health information.
“If one of my patients walks into an ER having a heart attack, and [the doctors] could access and see that [the patients] also have a panic disorder,” said Abbott. “If … somebody comes in and they’re having a hypertensive episode and they’re shaking and they have a seizure, but [the doctors] can see in their records they have alcohol use disorder — that could be alcohol withdrawal, and that treatment’s going to be really different.”
She also said that it could help her in the reverse situation — being able to see medical records for her clients. She gave the example of an older woman who might come in experiencing symptoms of depression for the first time. Having their medical records would allow her to see if the woman’s thyroid had been checked recently, and – with the woman’s permission – contact her primary care doctor.
But psychologist Marcy Russo also questioned who among the medical providers that a patient sees would be able to view their information.
“I’m a behavioral health patient and I sprain my ankle and I go to the emergency room for treatment of my ankle … in that instance, is it really necessary for those providers to have access to my entire behavioral health history and treatment?” said Russo.
Many of the behavioral health providers who spoke with CT Examiner said they believed that the information exchange should allow patients to consent to sharing medical data without having to also share behavioral health data.
“What is needed is a system that allows clients to opt out of behavioral records but not physical health care notes. Right now it is all or nothing,” said Wanczyk-Karp.
Russo said that, otherwise, this could put patients in a bad position.
“If you have a really complicated patient, let’s say, that’s receiving cancer treatment, but that also has behavioral health records that may indicate history of domestic violence, then you’re in a real bind, because that patient really might want privacy around their domestic violence records, but they absolutely need provider collaboration for their cancer treatment,” said Russo. “And so that puts the patient in a really difficult spot to say whether they opt out or not.”