"What's the best way to document information concerning psychiatric patients? I just don't know"-A qualitative study about recording psychiatric patients notes in the era of electronic health records.

Olga Chivilgina,Fabrice Jotterand,Mehdi Mohamed Benichou,Bernice S Elger,Maria Berghs

doi:10.1371/journal.pone.0264255

Abstract

This paper reports the results of a qualitative study regarding the main attitudes and concerns of Swiss psychiatrists related to the utility, usability and acceptability of EHR and how they address the pitfalls of sharing sensitive information with other parties. A total of 20 semi-structured interviews were carried out. Applied thematic analysis was used to identify themes with regard to participation. Three main themes were identified: 1) strengths of the use of EHR in the clinical context; 2) limitations of EHR; and 3) recommendations on preserving confidentiality in health records. The study shows variable practices of EHR use in psychiatric hospitals in Switzerland and a lack of standards on how to document sensitive information in EHR.

Highlights

Electronic healthcare records (EHR) have been used in Switzerland for several years, since a federal law on patients’ electronic health records (EHR) passed in 2015 and entered into force in April 2017.The technology aims at providing effective and high-quality care, since information exchange is beneficiary for the holistic treatment of patients, and it facilitates comprehensive evaluations and treatment planning
This study provides a unique perspective of variable practices of EHR use in psychiatric hospitals in Switzerland
The digitalization of psychiatric records is a source of many controversial ethical issues as exemplified in the use of EHR and electronic patient dossier (EPD) since the information in these records is sensitive

Summary

Introduction

Electronic healthcare records (EHR) have been used in Switzerland for several years, since a federal law on patients’ electronic health records (EHR) passed in 2015 and entered into force in April 2017. The technology aims at providing effective and high-quality care, since information exchange is beneficiary for the holistic treatment of patients, and it facilitates comprehensive evaluations and treatment planning. EHR are used in psychiatry but raise ethical concerns, as psychiatrists often deal with “very sensitive” information about their patients Psychiatric records often contain information on patients’ present symptoms, with a descriptive narrative of their life experience, including sensitive details of possible psychological trauma, domestic violence, incarceration, sexual encounters, and substance.

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Conclusion