Interoperability versus Confidentiality

June 4, 2012

This is my first blog post and I’ve ruminated about what to write for several weeks. After much thought, it occurred to me that one of the biggest conundrums facing the behavioral industry these days is the challenge of Interoperability versus Confidentiality. So, let’s take a few minutes to explore this issue.

The behavioral health business has always carried with it a cache of mystique. Those private, intimate conversations with a stranger. The apparent “magic” of psychotherapy. The stories of deep insights exposed for the first time in therapy, yielding miraculous life-changing behaviors. It all seems so strange and different compared to what we think of when we go to our family doctor.

On the other hand, admitting to problems of mental nature often led to real discrimination. Traditionally, people would lose jobs and friends when it was known that they had a mental illness. Loved ones would act differently towards those seeking treatment. Society and the media perpetuated erroneous stereotypes of the mentally ill. Who among us hasn’t heard or even told a joke referencing a “crazy” person or one that starts with “A drunk walks into a bar and…”? Mental illnesses and addictions have carried a huge stigma in western culture that has both necessitated protections and, in an odd, self-fulfilling manner, perpetuated the stigma itself. I wish I could tell you that we are more enlightened now and these stories are but sad recollections of a past pattern that no longer exists. Though it is better, discrimination and stigma are alive and well.

A friend of mine told me a story that exemplifies the problem pretty well. He has bipolar illness, formerly known as manic-depressive illness. It’s a disease characterized by extreme highs and lows far in extreme of what most of us ever experience. It is a disease that cannot be cured but it can be managed, usually through medications, and those afflicted with it can lead very productive lives with no one the wiser as to their condition. Such is the case with my friend who is very successful. He was mowing his yard one Saturday and the mower kicked up a rock that hit my friend in the arm necessitating a trip to the local emergency room for stitches. He was escorted to one of the observation rooms and asked to complete a short medical history. He dutifully disclosed the medications he was on, including the one for his bipolar disorder, and turned the clipboard to the nurse. In a few minutes, a security guard was posted outside his room solely because the attending staff recognized the medication he was on and determined he might be a threat. My friend was simply in need of medical care for his arm and was displaying no behaviors that would warrant a security guard. This occurred in a hospital where one might reasonably expect a more enlightened view. For problems like addictions, it’s even worse. People who admitted they were seeking treatment for an addiction were often fired from their jobs.

All the major ethical guidelines for behavioral health professionals require strict codes of confidentiality. State laws often contain penalties for disclosing mental health information or exemptions for mental health and addictions when disclosures are otherwise required. HIPAA codified the requirements for the exchange of ANY personal health information (PHI), not just behavioral health and, because of the unique sensitivity of addictions-related PHI, the federal government made release of these data even more stringent with 42CFR2.

Now, we are in an age of incentives for Interoperability between all healthcare providers. It has become clear that integration of primary and behavioral health information will result in improved clinical outcomes. The Accountable Care Act contained provisions that not only encouraged such exchanges but mandated them with penalties for non-compliance. Many Netsmart client organizations are stymied as they attempt to join health homes and other collaborative ventures with local medical providers because they cannot reconcile these two expectations.

So, what’s the answer? Do we abandon the confidentiality restrictions and risk significant real harm to people via discrimination and stigma? Or do we maintain the status quo, and risk people’s healthcare so their anonymity can be protected? There’s probably no Solomonic “split the baby” solution here. It’s either/or.

I believe it’s time we brought behavioral health care to the table in health care and err on the side of interoperability. I say this knowing the effects of such a change will be difficult for those with mental illness or addictions. But, I believe the alternative is worse. For too long, we have lived in a health care world where the head was disconnected from the body. We know that integrated care is better care. And, I believe that the secrecy surrounding mental health care perpetuates the stigma. It’s time we removed the negative “mystique” from mental health and replace it with another one that is equally awe inspiring – excellent outcomes.