Monitor on Psychology - February 2012 - (Page 74)

Practitioners need to have a security plan that provides adequate protection for either paper or electronic records from loss or damage. Electronic records The advent of electronic health records has radically altered the documentation landscape. At a minimum, electronic records are subject to similar concerns and requirements as paper records. Because of the rapid expansion of data technologies, the guidelines primarily offer general suggestions for managing information and electronic health records, such as using appropriate levels of encryption and passwords to protect digital information. The 2005 HIPAA Security Rule provides specific guidance on managing electronic protected health information. It applies to practitioners who must comply with HIPAA and who store or transmit such information. The rule requires that psychologists take special care in maintaining electronic records, and that they conduct a documented risk analysis of specified issues, and select security measures that are reasonable and appropriate for those risks and for the practice. Practitioners who do not have in-house IT departments should maintain adequate technological competence and consider using IT consultants for more complex security questions. The 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) encourages psychologists to adopt integrated electronic health records by 2014. States are now actively engaged in defining these new processes under HITECH. The law’s initial goal is to promote health professionals’ adoption of electronic health records. The next stage of the law’s implementation involves integrating medical records through interfacing with large, centralized data systems such as Health Information Exchanges or through systems of transactional, interoperable exchanges with other providers or organizations. Psychologists are encouraged to actively participate in developing state-level policies regarding the implementation of HITECH. Psychologists are uniquely qualified to advocate for enhanced security measures in handling sensitive mental health information, and to provide thoughtful insights on consent policies for health information exchange that allow clients to make informed choices about the sharing of their mental health information. organizational settings In multidisciplinary settings — such as community health centers, the VA or hospitals — records may be created or 74 accessed by many health-care providers. Health-care reform is focused on transforming delivery systems into collaborative or integrated care models, such as accountable-care organizations, that will share records through state or regional health information exchanges. As psychological services become integrated into larger systems of care, protecting the confidentiality of patients’ psychological records will become more complex (Richardson, 2009). In many settings, recordkeeping policies are already defined by applicable laws as well as institutional policy. Psychologists who work in these settings may not have full control over the record. However, they can advocate for record-keeping practices that meet psychological guidelines and also address the needs of other disciplines to coordinate care. For psychologists who work as independent consultants for organizations, it is important to clarify at the outset who owns and has access to psychological records. Guideline 10 addresses conflicts between organizational requirements, professional guidelines, ethics and legal standards. It is important to note that the 2010 Amendment to the Language of the 2002 Ethics Code, effective June 1, 2010, occurred after the guidelines revision and publication of the 2010 article this article is based on. “Language of the 2002 Ethics Code with Changes Marked” can be found at the end of the online 2010 Ethics Code at www.apa.org/ethics/code/index.aspx. Psychologists will find it useful to familiarize themselves with the amendments to Ethics Codes 1.02 and 1.03 when interpreting aspects of Record Keeping Guideline No. 1 Responsibility for Records and No. 10 Record Keeping in Organizational Settings. Multiple client records Documentation for couples, families and groups is one of the most complex and challenging areas of record keeping. Experienced psychologists usually develop a philosophy of documentation for couple and family therapy that fits their theoretical orientation, treatment model and practice setting. Therapists treating families or couples may document clinical information specific to individual clients, as well as describing the therapeutic process and relational data. Some psychologists suggest it is important to record the interactional essence of such treatment modalities (Gottlieb et al., 2008). Risk management considerations, such as anticipation of individual requests for release of information, the potential needs of highconflict families, and the potential for litigation, may encourage M o n i t o r o n p s y c h o l o g y • F e b ru a ry 2 0 1 2 http://www.apa.org/ethics/code/index.aspx

Table of Contents for the Digital Edition of Monitor on Psychology - February 2012

Monitor on Psychology - February 2012
Letters
President’s column
Contents
From the CEO
APA files two briefs in support of same-sex couples
New registry seeks to understand addiction recovery through ‘crowdsourcing’
APA launches a database of tests and measures
Watch for new member benefit: “APA Access”
Apply now for APA’s Advanced Training Institutes
PsycTHERAPY, APA’s new database, brings therapy demos to life
In Brief
APA scientists help guide tobacco regulation
A-mazing research
‘A machine for jumping to conclusions’
Judicial Notebook
Random Sample
Righting the imbalance
The beginnings of mental illness
Science Directions
Improving disorder classification, worldwide
Protesting proposed changes to the DSM
Interventions for at-risk students
Harnessing the wisdom of the ages
Anti-bullying efforts ramp up
Hostile hallways
R U friends 4 real?
Support for teachers
Speaking of Education
Record keeping for practitioners
Going green
At the intersection of law and psychology
Division Spotlight
Grants help solve society’s problems
Personalities

Monitor on Psychology - February 2012