The Importance of Keeping Patient Information Private

A uniformal aspect of psychology, among all practitioners, is the sacredness of patient confidentiality. However, just as no two psychological practitioners are alike, neither are protocols for confidentiality. Because of the flexibility of the confidentiality system, breaches are a common and problematic occurrence. The problems that come with the lack of an objective, universal system of confidentiality must be addressed and improved upon by the psychological community.

One of the few consensuses about confidentiality is that, in general, it is encouraged, ethical value in both psychotherapy and research (Stiles, 2011). Bersoff and Bulling discuss how the promise of confidentiality improves the relationship between patient and therapist, while Stiles reveals that the promise of anonymity is consistently found to increase the likeliness of an individual disclosing information. Stiles also insists that maintaining confidentiality is a gesture of respect to the patient and can even prevent identity theft in the research setting. However, another consensus is that confidentiality has its limits as a result of a subjective system that is currently not working.

A large part of what limits the promise of confidentiality is mandatory reporting, in which a practitioner actively leaks information as required by law or protocol. According to Stiles, despite the protection of patients by HIPAA, the constitutional freedom of information makes confidentiality less sacred in some cases. That is, HIPAA demands the concealment of personal information while the freedom of information demands its release; a dilemma that a mandatory reporter must navigate in a more flexible, ‘case-by-case’ system. Bersoff, for example, discussed how many people believe that a patient’s potential threat to themselves or others makes a breach in confidentiality acceptable, and thus expects a report. Mandatory reporting means that the psychological community must breach confidentiality in certain situations or risk prosecution. Bersoff’s article describes how these certain situations are sometimes defined by law, and sometimes are not. Although Hoyt implores that [military] psychologists must educate their patients on potential limits in case a breach must be made, Neilsen addresses the issue that patients may not understand who their information may be going to or what is being said, and thus aren’t truly giving informed consent. Hoyt gives examples of how confidentiality may be breached by military psychologists because of their roles as mandatory reporters. Some reasons for mandatory reporting are generally well known, such as threats to safety or child abuse or neglect. However, Hoyt also states that sexual assault, war crimes, and even substance abuse issues may be grounds for a confidentiality breach.

Mandatory reporting, however, is not the only means of breached confidentiality; sometimes confidentiality is not actively betrayed by the therapist, but is done in a more passive manner. One example of this is from a study done by Bulling, in which a survey was done about hospitals in which information seen by some healthcare and legal systems as confidential was allowed to be viewed by chaplains at a particular hospital. Luckily, Bulling et al. found the sharing of information to be an improvement; the study found that confidentiality was a barrier for collaboration in the care of a patient. Bulling et al. claimed that confidentiality would make it harder or impossible for sexual assault response teams, child protection, physicians, and other caretakers to get involved if needed. Ultimately, the results were more successful chaplains and happier, more responsive patients, as the chaplains better knew the predicaments of the patients. Although it is nice to know this study had a happy ending, it is an isolated study and it can easily be claimed that the chaplains and hospital were lucky; abuse, inflammatory scandals, or angry, untrusting patients could have just as easily been the case.

Another passive breaching of confidentiality can be caused not by the decision of the administration but by the overall vulnerable, unadaptable system. Bersoff has implied that the system protecting confidentiality is too undefined, and Nielsen and Smolyansky agree that the introduction of better technology makes the security worse, not better. According to Nielsen, little attention has been given to the steps that must be taken to make sure parents with proxy access to a confidential network are not allowed to access information not permitted to be disclosed by their child, the patient. Before confidential notes being introduced into an online system, this was not a problem; in today’s world where everything’s online, it is. Not only is the patient at risk for having leaked information, but parents or other family members are not clearly protected by this new network either. In response to Nielsen's work, Smolyansky et al. asked for and received four reports from four hospitals around the United States who were incorporating a new version of the electronic medical records into their workplace. Because no clear training or protocol was given on how to navigate this sensitive new network, each hospital had a different plan. Most of the hospitals set up some sort of committee, sometimes multiple committees, in order to troubleshoot issues with the network. However, a couple of the hospitals only set up the committees after the network was already in place and working in the hospital. Essentially, the hospitals agreed to fix potential damages from the unfamiliar system instead of trying to preventing them in the first places, despite the fact that breaches in confidentiality and the leakage of private information cannot be fully repaired. One of the hospitals ran into legal confusion, as the two states they operated in had different laws relating to confidentiality. A few also made their own rules of confidentiality more subjective than before, introducing the word ‘sensitive’ into the system. The word ‘sensitive’ essentially warned of potentially condemning or private content, but gave no legal or technical barrier to keep an unauthorized person from viewing it. A follow-up on any unauthorized breaches in confidentiality or problems taking place in any of the hospitals was not found. However, the efficacy of each hospital’s plan can easily be criticized as imperfect and in need of revision.

Improvements can be made both in the actions of practitioners and the system of confidentiality itself. For these improvements, each article offered their own suggestions. Stiles suggests practitioners, particularly researchers, seek legal advice in order to avoid mandated reveals of information, and to take as little personal identification as possible to eliminate confidentiality concerns altogether. Stiles also suggests a certificate of confidentiality as a means of extra protection for oneself and any obtained information. While Stiles’ idea of improvement is to protect confidentiality (and the psychologists defending it) at all cost, others have ideas on improving the system as a whole. Hoyt recommends that knowledge and communication about the limits of confidentiality is essential for both the practitioner and client, along with working with others to keep the limits of confidentiality to a minimum. Nielsen recommends training on how to properly use and protect electronic records. However, although mentioned in Stiles and Bersoff articles, suggestions regarding the navigation of differing legal definitions and protocols across the nation, and furthermore the globe, were not addressed.

Although all the improvements mentioned are good ideas, the suggestions only help a practitioner work with the system that is already in place. In truth, the system itself needs to be reworked instead of worked around. Psychology’s confidentiality system has too many ‘gray areas’ and could benefit with a more objective, rigid structure. Despite extensive discussion of the limits and flaws in the confidentiality system and suggestions for improvement, the psychological community is far from perfecting this important aspect of the practice, and will not reach better results unless the current system is dismissed for a better alternative.