Abstract
Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients’ primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems.
Highlights
Substance use assessment and treatment is occurring in health care settings such as primary care clinics, emergency departments, and trauma units
The Health Information Technology for Economic and Clinical Health (HITECH Act), contained within the ARRA, codified into law an executive order by President Bush from 2004 that created the Office of the National Coordinator for Health Information Technology (ONC) as part of the Department of Health and Human Services, which is charged with ensuring that all patients have a certified electronic health record by 2014
We provide some suggested actions that staff in substance use disorder (SUD) treatment programs can take to cope with these controversies
Summary
Substance use assessment and treatment is occurring in health care settings such as primary care clinics, emergency departments, and trauma units. The SUD counselor documents the details of the patient’s visit in the SUD clinic notes These notes are protected by 42 CFR Part 2 and are not accessible to others outside the program (in particular the patient’s primary care provider), without a specific release of information from the patient unless there is a qualifying medical emergency or an established QSOA exists. Solving a clinical conundrum: maintaining confidentiality in a coordinated care environment In 2010 an article in Alcoholism & Drug Abuse Weekly [7] asked, “Can electronic medical records and patient confidentiality coexist?” The answer appears to be “Yes, but they need to be harmonized.” People involved in this tuning process will include legislators, judges, attorneys, and insurance adjusters, but a major place where these issues will be acted out is in human service programs treating people with SUD. As the ethical standards continue to evolve in substance abuse treatment, it is essential that providers remain up to date on the latest ethical guidelines
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