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How much clinical information should we share?
For the past week or so I have engaged other physicians and nonphysician psychotherapists in a discussion about exchange of clinical information in the service of coordination of treatment. In my own practice a primary care physician prescribed psychiatric medications to a young man I was treating, and when I contacted the physician by telephone he explained that he did not realize I was involved in the man's care since I had not sent him copies of my progress notes, this despite the fact that I had previously discussed the case with him by telephone. A psychologist to whom I referred a patient for cognitive behavior therapy faxes me a copy of every progress note. I find that I rarely read the entire document, and I wonder whether it is worth the trouble to upload each one to the electronic medical record. Another physician whom I know well started a patient (whom I had been treating for years) on fluoxetine without contacting me by telephone or suggesting to the patient that he discuss with me whether medication might help his symptoms.
I often contact primary care physicians when I plan to assume care of one of their patients, but I have rarely sent progress notes or even evaluation records, and the physicians have rarely asked me to do so. I almost always contact involved psychotherapists, but generally it seems that we both assume that transfer of information will occur only as indicated. (It has bothered me some in the past that this means that if the patient drops out of treatment with one or the other of us, the other may not know.)
From what I have heard from colleagues it seems that only the rare psychiatrist makes a practice of regularly sending copies of records. Providing records on a regular basis take even more time than receiving such records.
The response from primary care physicians generally involves some resentment that despite their best attempts they have little success in engaging psychiatrists in regular communication. In fact many report that psychiatrists do not even return their phone calls.
In my experience patients have seemed reluctant to divulge personal information they assume my records will contain to their primary care physician. I do attempt to omit from the record information I deem sensitive, however sometimes I consider such information critical to documenting justification for treatment decisions and include it.
Of course, the patient has ultimate control over who sees their record. I have often received signed authorizations from other providers, but when I contacted the patient to request that they sign my authorization and confirm that they do in fact want the records released, either they deny authorization, or they do not respond at all. Ultimately, I always consider that the patient assumes ultimate responsibility for failure to release records.
This is yet another area in which the cloud-based electronic medical record could save time and minimize error. Neither clinician should have to transmit records to the other. The patient should simply have the power to decide which clinician can access their record. The electronic medical record might also have the capability to alert other providers to updates, allowing them to keep abreast of changes in treatment, especially those that might impact their own management of the case.
I have resolved to more aggressively question other members of the treatment team before arriving at a plan for exchange of clinical information.