The Patient-Therapist Relationship: Reliable and Authentic Mental Health Records in a Shared Electronic Environment

Article excerpt

There are currently a number of initiatives in Australia and internationally that are aimed at sharing patient data among healthcare providers, as well as other third parties. This article analyses the impact of one of these projects--HealthConnect--on the reliability and authenticity of mental health records by assessing the adequacy of evolving electronic health records standards, as well as mental health records standards. Although the analysis found that mental health services could benefit from the sharing of information between healthcare providers, the HealthConnect proposals and standards activity highlight the paucity of specific measures in place to differentiate mental health information from other health information. Research also indicates that current proposals do not meet record-keeping benchmarks of authenticity, which require the ability to reconstruct all elements of a record's identity and integrity overtime--essential to protecting the rights and obligations of the patient, therapist and other third parties. Finally, the article proposes a technology-neutral conceptual model for identifying the trustworthiness of mental health records in a shared electronic environment.

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At the Health Information Management Association of Australia's national conference, held in Sydney in August, 2003, Professor Marie Bashir, the Governor of New South Wales, and herself a psychiatrist, recounted the story of one of her former patients who contacted her to ask for documentary evidence of a diagnosis she had made of his mental illness, 10 years ago. She was able to provide him with the information he was seeking from her patient notes in order for him to demonstrate an intellectual disability of long duration. Her records of the patient in question were in paper form, they were readable, they were her intellectual property, they had not been divulged to any third party and they had not been tampered with. Because she was both the author and owner of the records, their reliability was assured by her professional accreditation and the fact that it was her normal practice to keep all related papers of each patient together in one file. Will this be the case in the following 10 to 20 years when the record will have been created and stored in electronic form, and the identity elements of the record, (i.e., who created it, when and where) are not stored with the data or held by the author, and its integrity cannot be guaranteed because the software that is needed to read it no longer exists or its migration to a new system has not retained all the essential data?

In the mental health context, without proper clinical documentation the patient is denied rights to a full and accurate record of diagnosis and treatment, and the therapist has no evidence of the diagnosis and treatment given for both immediate and future uses. Individual clinical documentation also illustrates how mental health policy has been implemented at a given point in time that goes beyond the individual's treatment by providing professional and collective accountability for particular kinds of treatment methods. The clinical mental health record is a record of patient care in the context of a mental health service, shared within the boundaries of medical confidentiality between the health service provider, patient, family, carers and advocates. It is essential to establishing the rights and obligations of the parties in the action recorded. As mental health issues are episodic, the treatment record needs to be preserved for the lifetime of the patient.

Electronic health records, and in particular those that are shared outside their creation boundary, need to be retained for the lifetime, and possibly beyond the life of the patient to provide healthcare continuity and accountability. In fact, current electronic health record models refer to the "longitudinal" record that can be either a single encounter or any length of time (ISO Standards Group, 2003). …