Confidentiality of the right thing

If we use “issues” as the top level item in the EHR, instead of the “encounter”, it comes naturally to attach confidentiality attributes to the issue instead of the department, doctor, or encounter. That’s a huge improvement. Let’s take an example to show why.

As things are in current systems, confidentiality walls or borders are located around certain services. The reasoning goes that if a patient doesn’t want his psychiatric problems to be known, then any records entered by the psychiatrist should be confidential and not accessible by other specialities. This is so screwed up. The psychiatrist is usually the one that handles embarrassing psychiatric problems, but this is not necessarily so. The psychiatrist may actually treat the patient for something entirely un-embarrassing like a headache or irregular menstruation or hives, and does that mean that the patient’s hives now are confidential? Of course not, but that’s not how the systems we have reason.

Let’s take another example. If I, as a GP, treat a patient for syphilis, there’s no confidentiality attached to it. If the same patient was treated for the same disease by a venereologist, then there is confidentiality. This is bloody nonsense, but this is how things generally work. In the system I’m working mostly, that is not a problem, since no confidentiality is implemented at all. (Don’t ask…)

It must be obvious to most that it is the “issue” that should have confidentiality attributes attached. If the patient doesn’t want the news about his syphilis to spread, the issue “syphilis” should be confidential, irrespective of which doctor or speciality that treats the patient. It’s up to the patient to decide if he wants any other particular specialist or department to know about this diagnosis.

The danger with all these confidentiality limits is that a disease that normally isn’t important to the treatment of another disease, may occasionally be extremely important, but remains hidden. If confidentiality is attached to issues, and issues to the patient, then there is the possibility of the system warning the user of hidden pathologies that are important, simply since this system actually knows what an issue is, and that other issues may include warnings about the simultaneous presence of these issues, including pharmacological interactions.

For instance, our syphilitic patient has a problem with suspected neuropathy, but the syphilis is hidden from the neurologist examining the patient. If the clinical guideline for “peripheral neuropathies” includes the differential diagnosis “syphilis”, the system is able to warn the physician that there are hidden issues that are related to the workup he is currently performing and that he should take steps to be allowed to unlock this information.