In Electronic Health Information, Who Decides Which Info is "Sensitive"?

I participate in a committee that establishes policies for our state's health information exchange (HIE). The HIE is the electronic infrastructure that permits hospitals, physician groups, labs, imaging companies, pharmacies, and others to share information about patients. The idea behind the sharing is to make it easier for your primary care doctor to share your health data (ideally, with your permission) with your cardiologist and your dermatologist. The potential benefits to this sharing include:

• quicker exchange of information than with faxing or mailing
• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)
• better tracking of who accessed what information
• less duplication of tests ("I know you had a CAT scan at the other hospital last week but I can't wait for the results to be sent to me so I'm getting another one.")
• improved coordination of care
• fewer medical errors due to more information available
• decreased liability due to sharing of important information with other providers

The potential risks include:

• decreased privacy due to potential for data breach, identity theft
• loss of data due to technical problems (viruses, hardware failure, etc)
• failure to secure data due to inadequate authentication, authorization, encryption, etc
• more errors in health record due to automated data collection processes
• increased liability due to sharing of sensitive information with other providers

I wanted to talk briefly about this notion of "sensitive health information." Our committee has spent many hours discussing what this might mean and how to define it. One view is that all health information should be treated as "sensitive," while another is that only certain categories of health information, such as mental illness, substance abuse, HIV status, domestic violence, abortion history, and genetic data, should be treated with additional safeguards against inadvertent access or disclosure. This latter viewpoint promotes the stigma about mental illness that we have been trying to erase.  It wasn't so long ago that epilepsy and cancer might have been on this list. My viewpoint is that patients should be the one to decide which elements of their health information should be treated with extra precautions and which should be considered routine.

This was ultimately agreed upon by the other committee members, but it still didn't help us much because the technology for patients to review their health information and mark which bits should be tagged as sensitive is not yet built into nearly any of the electronic health record products or the HIE systems. There is no standard for doing so nor is there even any agreement about how or whether it should be done. Groups like healthdatarights.org and speakflower.org have promoted these ideals, but we are not much closer to achieving them.

Anyway, I discussed this topic in my Shrink Rap News blog post this week over on Clinical Psychiatry News. Read more about it over there. If you are a psychiatrist, log in or register on CPN and join the discussion (my mistake -- other professionals and also consumers are allowed to register over there).

Hanging On

It's been a little quiet here at Shrink Rap this week, in between the earthquake and the upcoming hurricane. Please bear with us. If we have power this weekend (and if Dinah has her network back up) we may try our first-ever videoconference podcast.

In the meantime, best wishes to all our readers and listeners in the path of the storm. Please heed precautions and take care of yourselves!

See you on the other side.

In the meantime, you might be interested in reading a followup comment on my Clinical Psychiatry News post about the psychological autopsy done on the alleged anthrax mailer, Dr. Bruce Ivins. Not surprisingly, the expert behavioral analysis panel (EBAP) disagrees with me. They feel they did the right thing by publishing and selling his medical data. Read the EBAP response.

How to be a Successful College Student

It's Labor Day and kids are getting ready to go back to school.  The Shrink Rap duck pictured here is getting in his last moments of holiday relaxation, and I am so happy to be up and running on my new Macbook pro.

Here at Shrink Rap, we don't offer medical advice, so this is not medical advice.  It's not based on anything even vaguely resembling evidence-based medicine, but I have treated many college students over the years and I have been impressed by those things that seem to make or break the college experience.  Back-to-School, but none of us treat the under-18 crowd, so my bullet point suggestions are limited to college students.  If you're a parent, feel free to send this to your college student, and if you're a student, feel free to ask "Who are those blogging shrinks with the duck? They must be quacks." 

Here are my quick & dirty pointers for how to succeed in college:

1) Show Up.
Being present in class, on time, in a state that vaguely resembles conscious is most of the battle.
If you don't go to class, with the exception of the unanticipated onset of a febrile or gastrointestinal illness, then you should know well in advance that you're not going to go and have a strategy for how you are going to make up the work.  By these criteria, "I don't want to get out of bed" doesn't work.  But "The professor doesn't speak English and lectures straight from the book, so it's a better use of my time to read the book and get notes from my roommate who takes great notes," may be a valid reason to skip class.

2) Don't smoke weed.
This is a tricky one-- many college students smoke weed (or at least those who end up my office almost all do).  Some people smoke marijuana regularly and still seem to live fully productive lives.  Some people seem to find it very "beneficial" to them even though it appears to be killing their motivation and decreasing their anxiety to the point where they have no ambition, barely move,  and don't do the things it's necessary to do in order to succeed, for example #1 above: Show Up.  Oddly enough, marijuana smokers do not see the connection between their  low motivational level and their low success status and they are absolutely sure their consumption of marijuana has nothing to do with their problems.  They become very skilled at telling others why weed isn't part of the problem and many are quite well versed on the rhetoric of NORML and how the it's a political agenda to keep marijuana illegal.   If you're not successful and you smoke weed, stop and see if your life gets better.  Oh, and by the way, two weeks off is not a 'trial.'  Don't smoke at all, ever, for 6-12 months and see if you're in a better place.  If you are successful and you smoke weed, you're probably not reading this article, but even in the best scenarios, it increases your risk of lung cancer and it causes the munchies which can make you fat, and if you get caught and arrested it's a lot of explaining to do for a very long time.   

3) College Students and Drinking.
This is even trickier because while there are college students who don't smoke weed, the role of alcohol in college life is huge and the pressure to drink is immense.  It's not legal if you're under 21, it seems to lead to all sorts of problems, but it seems to be an impossible sell to college students, so let me make suggestions based on the assumption that there is nothing I can say that would stop anyone from drinking:
--Don't drink on any night when you need to be somewhere the next morning.
--Don't drink enough that you vomit, pass out, or black out.
--Don't drive after you've had anything to drink: being dead is a lot worse than not finishing college.
--Keep your total consumption under 15 drinks a week for a man and 8 drinks a week for a woman.
--If you can't keep abide by the above suggestions, you have a problem and should get help.
NPR had an interesting show on Why College Students Drink So Much and Party So Hard about a book by Thomas Vander.
Add to the How to Stay Alive Issue :  Before you go out drinking, Eat.  If your friends pass out, roll them on their side and don't ever leave someone who is passed out alone.  If they really can't be aroused to at least push you away and groan, call an ambulance.  Don't do shots.  Beer pong is more fun and much safer. Don't drink in settings where you may be sexually vulnerable.

4) Get enough sleep.
If this means not scheduling early classes or taking naps during the day, then consider those things when you set your schedule, but sleep is really important.

5) If you have a psychiatric disorder, don't stop your treatment.
It's not unusual for kids to try this when they go off to college and don't have the 'rents handing them medications or driving them to therapy appointments.  It's a really bad idea.  Particularly bad times to cease treatment are first semester Freshman year and any year during mid-terms or finals.    I'll add: if you have a psychiatric disorder, don't drink, it makes everything worse.

6) Take a large, heavy brick and throw it through your Nintendo/PlayStation/XBox.
  Ditto for online fantasy games.  Anything outside of school work or employment that captures you for more than two hours a day may be a problem.  Reading psychiatry blogs is fine.

7) If you're a sensitive or problem child, don't have a roommate who shares the same bedroom with you, it adds to the stress of college and it's helpful to have space you can escape to.

8) If you're having a rough time, get help.
If you're struggling in class, talk to the professor and consider getting a tutor.  If you're very depressed, call the counseling center.  If you're feeling sick, go to the health center.  College is not the time to suffer alone.

9) Know the final drop date for your classes and if you're failing, drop the class.  Remember to turn in the form.

Anyone want to add to the list?
Best wishes for a happy, fun, and educational school year.