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In a survey of psychiatry departments at 18 of the top American hospitals as ranked by U.S. News & World Report's Best Hospitals in 2007, a Johns Hopkins team learned that fewer than half of the hospitals had all inpatient psychiatric records in their electronic medical record systems and that fewer than 25 percent gave non-psychiatrists full access to those records.
Strikingly, the researchers say, psychiatric patients were 40 percent less likely to be readmitted to the hospital within the first month after discharge in institutions that provided full access to those medical records.
"The big elephant in the room is the stigma," says Adam I. Kaplin, M.D., Ph.D., an assistant professor of psychiatry and behavioral sciences and neurology at the Johns Hopkins University School of Medicine and leader of the study published online in the International Journal of Medical Informatics. "But there are unintended consequences of trying to protect the medical records of psychiatric patients. When you protect psychiatric patients in this way, you're protecting them from getting better care. We're not helping anyone by not treating these diseases as we would other types of maladies. In fact, we're hurting our patients by not giving their medical doctors the full picture of their health."
Kaplin says that as more and more hospitals embrace electronic medical records, many choose to exclude psychiatric illnesses, even if that means keeping vital information about diagnoses and medications from primary care doctors who need it.
After the surveys were completed, the researchers tapped the University Health System Consortium Clinical Database, which includes information on readmission rates on 13 of the hospitals in the study. At institutions where psychiatric records were included in the EMR, psychiatric patients were 27 percent less likely to be readmitted to the hospital within a week of discharge, with little statistical difference after two weeks and a month. But in those hospitals where records were included in the EMR and non-psychiatrists were given access to them, patients were 40 percent less likely to be readmitted at seven days, 14 days and a month.
"If you have electronic medical records, that's a good step in the right direction," Kaplin says. "But what you really need to do is share the records with non-psychiatrists. It will really make a difference in terms of quality of care and readmission rates. Let's not keep mental health records out in the cold."
The researchers found no difference in length of stay in the hospital, a marker for severity of illness, between patients whose records were shared or not, nor was there a difference found in overall readmission rates at the hospitals, suggesting that the higher readmission rate for the patients whose information was not shared was a psychiatry department issue, not a hospital-wide one, Kaplin notes. Readmission rates have been a hot topic because the federal Centers for Medicare and Medicaid Services has begun to penalize some hospitals financially for readmissions, seen by many as a marker for poor quality of care.
Kaplin argues that while non-psychiatrists don't need access to all of the specifics of a patient's psychiatric history, they need to know details about diagnoses, treatment and medications prescribed. The latter is perhaps the most vital because drugs prescribed by a primary care doctor could produce bad interactions when mixed with psychiatric drugs that they are not aware have been prescribed by a psychiatrist.
Kaplin says it makes no sense that a physician can find out if a patient is being treated at the HIV clinic, for erectile dysfunction or for drug addiction, but not whether the patient is being treated for depression.
Information about depression can be critical, Kaplin says, because depression after a heart attack is the number one determinant of whether the patient will be alive one year later. Moreover, he says, by keeping psychiatric records separate, the stigma is perpetuated.
Hospitals take great care to ensure confidentiality of patient records, electronic or not, and that information is used only by those with a need for it. With electronic records, each access leaves behind an electronic fingerprint, and if someone without authorization accesses the records, a red flag goes up. Hospital staff members have been fired for improperly viewing medical records.
