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>> My name is Martha Perry.
I did an adolescent medicine fellowship at UCSF
and actually completed the last six months of it in Boston,
having been a pediatrics resident there
and then came back to finish up fellowship
when my husband decided to change coasts for his job.
And then worked in academics for a while and then went
into private practice mainly to have more structured time
at work as well as at home with my kids.
And it's actually been a fabulous experience to learn how
to provide efficient and effective adolescent care
in a managed care environment.
So, part of why they asked me to speak today was to talk
about some of the challenges that we come up with some
of the strategies that we use
and I don't have all the answers,
but I definitely have thoughts and ideas
and I also welcome your thoughts and ideas as well.
Just to kind of think about why I said adolescent-friendly,
you know, my philosophy is that adolescence is a complex time
where the provider-patient relationship is really
challenged because of the occurrence
of multiple biocycle social changes, experimental
and risky behaviors that are occurring, parental
or family conflict, peer influences,
social media influences,
all of this complicates our relationship with them.
They need a listening ear that they can trust
to keep it confidential and that doesn't pass judgment
or lecture them.
This is something all of you know because you're here today.
Listening to this parental involvement maybe warranted.
In fact, I often encourage it and it's often very helpful.
But the adolescent has to help determine what the extent
of involvement is.
What I'm going to do is review consent and confidentiality
as it pertains to standard of care for adolescents.
I'm going to talk about some of the approaches that we take
and the, again, managed care setting but is relevant
to any adolescent clinic in terms
of maintaining their privacy and providing a safe place for them
to come to get all of their concerns addressed
in a sensitive way.
I'm going to talk a bit about charting and some of the systems
that we can use or some of the things to keep in mind
to prevent stigmatization as well
as to prevent breach of confidentiality.
I'll have examples but also welcome you
to have examples as well.
Raise your hands, makes this an interactive discussion
that makes it more interesting for all of us
because we all have stories.
And we'll talk a bit about billing--
to ensure adequate reimbursement and also
to ensure confidentiality.
Just as a little bit of background,
76 percent of adolescents said they wanted confidential care
but only 45 percent actually thought
that their clinician could or would provide it
and only 28 percent reported their provider actually
discussed it directly with them.
So that's basically about a quarter or less than a third
of patients that actually have been told about confidentiality
by a provider in this particular survey.
Confidentiality is particularly relevant with *** healthcare
which is a lot of what we're talking about today.
And in-- a survey of Title 10 clinics,
59 percent of girls receiving contraceptive services said they
would not come if it was not confidential.
And of course, not surprisingly only a small percentage,
one percent of them would actually change their ***
activity related to that.
Thirty-five percent
of the students surveyed said they would not seek--
they have not sought care
because they don't want their parents to know.
So, adolescents are more willing to communicate with
and seek healthcare from physicians
who assure confidentiality, and adolescents are more likely
to discuss particularly sensitive topics
if they are proactively instructed by their provider
around confidentiality.
One of the things that I think a lot of people assume
that adolescents understand consent and confidentiality
or assume that parents understand,
a lot of parents are surprised
when I tell them there are certain things your child can
consent to without your knowledge.
And I will go over that, whether it's relevant to the patient
or not, at some of the initial visits because I want them
to know that their child can consent
to reproductive healthcare
at our clinic their child can consent
to mental health services or can consent
to certain mental health services,
can consent to substance abuse services,
and also that they can discuss these issues with me
and then I'm not going to share that information.
When surveyed, no more than half reported most MDs would provide
confidential information.
And even after conditional assurance of confidentiality,
only 28 to 36 percent really believed they would get
confidential STD care.
And that's a big problem.
I have definitely had patients who say,
I know you tell me it's confidential but there are
so many different ways that my parents can find out.
And so, you know, it sometimes will have an agreement
about what I write in the chart or don't write in the chart,
and we'll talk about charting and how to get around that.
But it gets complicated.
The conditional assurance
of confidentiality is also really important.
So many adolescents don't know they know they have
confidentiality but they don't know the exact conditions
around it.
And that we do need to at times reveal information
if they're in danger.
So this is a statement that Carol Ford wrote
that is just sort of a narrative that, you know, can be used.
And oftentimes what I'll say is with the parent
and child together, I will say, "Everything that we talked
about once you leave the room that pertains to sex, drugs,
alcohol, tobacco, feelings, et cetera,
I cannot discuss with your parent.
You can discuss it with your parent and I encourage you to,
I think that's very important.
But I can't discuss it with them.
In fact, it's actually against the law for me
to discuss it with them.
More importantly, I respect your privacy
and that's why I wouldn't discuss it and I leave it to you
to choose what you're going to discuss.
But I need you and your mom or dad or whoever is there to know
that prior to us entering into this discussion,
and for people to acknowledge that."
I've only had one parent actually refuse
to leave the room, when, in my private practice setting,
to refuse to leave the room, when I've gone over this.
And she actually recently switched practices
because she was upset that I asked her daughter
about gender preference.
Because I went-- I still went
through all the questions in her presence.
How many of you have had objections
to confidentiality for your patients?
And what kind of examples-- give me your examples.
What happened in those situations?
>> Well I was in the ER and then [inaudible] there was a 14 year
old girl
who came for burning urination, the mom thought it was UTI.
I ended up checking for chlamydia in a room,
'cause I had confidential questions for her and then,
you know, I've asked the mom to step out
and then asked all these questions.
So mom came back and she was asking what treatment I was
giving to her.
She wanted to know what is-- the girl is working and, you know,
she started arguing, this is my little girl
and we are sitting there, you know,
it's not [inaudible] or something.
>> Yeah. And it's very hard because when you run into,
do you tell that-- you can't really give the parents an
accurate diagnosis or you can't tell them the truth.
But then if you can't tell them,
then they assume it's something bad.
And so, sometimes, I will counsel with the patient a means
to be able to tell their parents.
And many times, I'm actually able to convince them
to tell their parents what they've been diagnosed with.
I often find that's what goes the best.
Or ideally, I don't obviously coerce them into that.
I just say, you know what?
I think they're probably going to find out about this.
So let's figure out how to tell them.
Do you want to tell them together
or how do you want to do it?
And in certain situations like that,
where everyone is right there,
and they want answers, it's harder.
We used to run into that that a lot in the ER as well
when we had consults when we were at--
when I was an adolescent fellow at UCSF.
And generally we would just use very nonspecific terms.
We'd say, "Oh yeah they have an infection in their urine
and we need to get some medicine to clear it up."
And sometimes, parents would accept that, more savvy parents
or parents who are
in the medical profession wouldn't accept that.
And that's where there's only so much you can do as a provider
to guarantee the confidentiality but I think that it is okay
to stretch the truth in terms of what you're actually treating.
What other examples?
>> Well I work in a pediatric setting, so you know,
we got patients who are engaging, maybe hurting
or cutting or they might be very impulsive
and they're risk-taking.
I mean, that's considered if you have a 14, 15-year old.
Is that something to let the parents know
that the person is engaging in behaviors
that are essentially self-harming?
I mean, how do you define what's harming to the person
that is so broad or so--
>> Yeah. Yes.
And we'll get to that.
I think that it's-- one, it's important that you develop,
that you have a policy at hand that's in your office
which is what-- it's sort of is mentioned on this slide
and that you're clear with it from the beginning
with the patient and the parent.
So that you-- you're discussing with them what you're going
to share and what you're not going to share.
And so, it's really about weighing what the rights
of the patient are and what the rights of the parent are
and obviously you want to protect that young person
and take care of them and they may not be able
to make very good decisions.
They're thinking with their amygdala,
the rest of us are operating with our frontal lobe.
And so, how much independence do we give them?
But, at the same time, they do have a desire
to make their own decisions.
And sometimes it's the best for them in terms
of their developmental stage or in terms of their safety
at home, or their recovery from their disease--
that information is not shared.
So, what I recommend is that it's-- it has to be justified,
so it has to be something that's life-threatening,
something that's serious chemical dependence,
where again that their life might be in danger, or suicidal
or homicidal ideation.
I don't consider cutting a suicidal behavior.
I consider it a sign of stress and concern,
and I express that to my patients.
And I encourage them to share it with patients,
and often parents have already noticed it or aware of it.
>> That patient, we did 15 stitches, when it's [inaudible].
>> Right. And so that becomes more, you know, more towards
and more significant harm to self.
But again, I would argue, that's not life-threatening.
I think that if it--
if the intention was to take their life, which is important
in terms of finding out the intent, then it is something
that you would want to share with the parents.
And it should always be a discussion with--
that's if the adolescent, as we talked about,
I will say to them, I'm very concerned about your behaviors.
You've been water loading every visit.
I told you not to water load this time.
You lost six pounds.
I need your parents to know that.
And they don't want their parents to know that.
But I need them to know because we need to change your level
of care or we need to alter your treatment plan in some way.
And oftentimes, you know, I believe that most of the time,
we should be meeting with parents
and adolescents together, that those are times
when they bring the parent into or-- I talk to the adolescent,
we do a sort of-- I repeat to them what I'm going to talk
to the parent about and I will talk to the parent separately.
Because what I'm going to try to do is stop the parent's reaction
that will negatively affect the outcome.
So, I don't want the adolescent to think I'm
in the other room talking about something
that they don't want their parent to know.
So I say here's what I'm going to say to your parents.
I'm writing it down.
This is an outline of what I'm going to say.
And I go and I talk to the parent about it.
And I say, this is what Susan and I decided that we are going
to talk to you about and that we really want you to know.
And what I do is help them gauge their reaction.
So, they'll often say things
that I do not want their child to hear.
And so, I don't want to announce certain things to them
until they've heard it, they've process it with me.
It takes a lot of time in the office but then we go back
and we'll get to building on time later.
But, and then I'll go back in the room and I'll repeat it
with both of them present.
So, I'll say, this is what I told your mom, you know,
do you have anything else you want to add.
And I'll let the parent sort of--
we'll rehearse even together
about how they're going to respond to it.
And what they're going to say.
So, I find that's often helpful.
And most times, I'm able to convince the patients
to share what's necessary to allow them to get the level
of care that they need.
Again, we kind of run over this already.
But, just explaining what you're going to say
to the parent is key and letting them know
that you really do respect their privacy.
That yes, it's against the law.
They could-- I'll say that to patients, you could sue me
if I reveal confidential information.
And they always think that's kind of funny.
And I say, I'm not doing this because I'm--
I'm not keeping this confidential
because I'm afraid you're going to sue me.
I'm doing it because I respect your privacy
and your right to privacy.
But I want you to know that is a law because sometimes,
other people don't respect that and you need to know that.
In terms of who's entitled to confidential services
and which ones, what states are people from here, Massachusetts,
Rhode Island-- anywhere else?
Connecticut?
Oh that's right.
Beause Connecticut's actually fairly progressive in terms of--
some of the reason changes on EOBs which I'll get to.
But, all minors according to federal law are entitled
to consent for family planning services other than abortion
in certain states, in Title 10 clinics
or by Medicaid providers.
Every state has its own statutes that allow minors
to consent to certain things.
So are people aware of what they can consent to,
pretty comfortable with that?
>> I'm not,
>> Sure. So which state-- what state are you in?
>> Rhode Island.
>> Rhode Island.
So, I know the Massachusetts ones,
but to find out what your minor consent laws are there's a
variety of different ways, the easiest way.
And there's a slide at the end of this
and this slide will be available online for--
they give some websites but the Center for Adolescent Health
and The Law is really the best resource that summarizes
and regularly updates, consent and confidentiality by state.
>> I can actually answer it, so, adolescents here can consent
to substance abuse or mental health treatment.
They can consent to STD treatment.
They can't actually consent or without parental [inaudible]
to contraception or prenatal care.
>> They cannot.
>> They cannot.
And then, and they--
>> I think so.
>> -- pregnancy-- so, it's kind of de facto in Rhode Island
because actually, you can-- the way that the laws are written,
you can choose to follow-- I would feel protected, you know,
by the laws to practice however I see fit,
as far as confidentiality goes.
But, because Rhode Island is a small state,
the hospitals are particularly the ones in Providence.
All kinds of practice, this idea of kind
of what they're most comfortable with, you know,
in terms of where independent repercussions can happen.
So, in that sense, it's de facto that you can't,
you can't give information about contraception
or distribute contraception or pregnancy prenatal care
without parental notification.
That doesn't mean they have to be in the room
but they would need to get [inaudible], no, get a letter
from them or something saying it was okay.
>> To provide contraception--
>> Right, or [inaudible].
>> You do?
>> Yes. And then-- you have to have parental permission.
And this might be some-- another issue, it's for abortion
or adoption or like the adolescents can't consent
to that.
>> There are a very few states where an adolescent can consent
to abortion without parental consent.
California is one.
Most states have-- not most,
but several states have relatively easy way
to bypass the parental consent, going before a judge
in an expedited way like Massachusetts.
As I said, because of the federal law, technically,
most states are supposed to be able
to provide Title 10 contraceptive
or reproductive health services other than abortion.
>> So that would be in Title 10 centers, right?
>> Correct.
>> And not in any place [inaudible].
>> Right. Well,
and participating Medicaid providers.
So, that means for instance,
my clinic which is a private practice,
but we have Medicaid patients, technically,
you know that-- we'd fall under that.
In terms of age cut-offs,
that is one thing that's important to know.
There is no age limit
for reproductive health care consent.
So, any aged child
or adolescents can receive reproductive health care
in the state of Massachusetts.
There is no definition of age.
Assessment start at 12 or whatever,
there is no specified age.
>> Beause definitely the ones screened is reproductive
health care?
>> Yes. Oh, I'm trying to remember,
I just literally was reading it two days ago.
It's health care related to reproduction
and sexually transmitted infection
or something along those lines, that's not exact--
the exact wording but it specifies both of those.
And then maybe *** health might be a better way
of describing it because the reproductive health would
technically include abortion.
And that's obviously not included in Massachusetts.
The other important thing is that for mental health
and substance abuse, there are age cut-offs.
So are you guys aware of the age cut-offs
for consent in Massachusetts?
So, I kind of don't follow this but technically,
it's age 16 for substance abuse treatment facilities to be able
to consent and to have the right to confidentiality.
And it's 15 for mental health.
So that's actually what's written in the laws.
I don't think that people follow that generally.
I think that we assume that it's confidential, but technically,
you know, some of us are going to really push the issue,
there are specific age cut-offs for those two areas.
In terms of minors being able to consent to any sort of service,
you can declare them an emancipated minor.
And the way that you can declare them emancipated minor,
which is kind of interesting, is by declaring
that there is an intended pregnancy
or that they're seeking care related to pregnancy.
So some lawyers will get around that loophole
to basically say they can consent for anything
without parental consent because you're defining them
as an emancipated minor.
And the definition
of an emancipated minor can sometimes be loosely worded
to allow that.
>> Am I correct?
I thought Massachusetts still in the [inaudible] per se?
>> For-- they do for regular medical care.
So, for the specific areas we're talking about,
for confidential care, they don't.
But for just regular medical care, they do.
So it gets confusing because our lawyer--
for instance, we just had a case recently of a young woman
who was *** and came in for care.
I wasn't the one who took care of her
but the provider did a variety
of different STD tests including ***.
She is 17.
She has signed consent, went to the lab, everything was set.
She went to a *** crisis center, they called
and they asked us to fax over the lab results.
We needed consent.
So the mother was called.
Or no, the mother called actually, I'm sorry,
from the *** crisis center and said I'm here with my daughter,
she's been ***, we'd-- they need the information,
can we have the results faxed over?
So we need a consent, the mother signed the consent,
they faxed over the results.
What's wrong with that?
>> *** test?
>> Yeah.
>> She's the only one who can consent.
>> Right, so the minor is the only one
that can consent for that to be faxed.
And not only that, you can't fax *** test results.
Yeah, so there were two things that went wrong with that.
And there was a very, very nice administrative person
on the other line who is really trying to be helpful.
Because the mom was desperate at the *** crisis center,
I need this right away, you know, can you do this for us?
The daughter was right there, but technically that's a breach
of confidentiality and consent.
But what's interesting is that when it got brought
to our risk management, our lawyer, he said that the,
in order to do the *** test, that we had to document
in the chart, in some capacity,
that the child is an emancipated minor.
So that's how I ended up investigating
which just what happened this past week,
more thoroughly an emancipated minor, regulations.
And you do not need to document
that for anything that's *** health-related,
mental health-related or substance abuse-related.
But for other medical care like, you know, a sore throat
or whatever, you're technically supposed to.
We do it all the time.
We had a lot of adolescents walk in.
We swab their throat.
We don't talk to the parents.
We send them home.
But technically, they are supposed to be
in some way emancipated in order to consent
for that care, which is interesting.
The other interesting thing is that, there's a lot
of different regulations in terms of sharing information.
So for instance, in terms of the HIPAA rules,
that technically provides protection
as well to the adolescent.
So then technically they're not supposed to--
we're not supposed to release even minor's health information
if it's protected in some way by confidentiality law.
So in addition to the person who sent over the *** test
when it wasn't consented properly and it was faxed
and it shouldn't have been faxed 'cause you're not supposed
to fax *** results, it was also technically a HIPAA violation,
which isn't a big thing,
except that you can get a hefty fine with that.
In terms of consent and confidentiality,
the biggest thing that comes up a lot is EOB, so Explanation
of Benefits, when we're dealing with the managed care companies.
How many people have run into that as an issue?
So, tell me more about that.
Did you have a managed care company
that sent an Explanation of Benefits?
And they've-- the parents have objected to it
or what's-- tell me the scenario?
>> Basically, in terms of the counseling, like the adolescent,
like I have to, because of the way our practice runs or because
of the insurance of it, have been actually warned of that.
You know, I'm willing to give you this.
But you have to be aware that the parents would proceed
with the value because of these duplications going
to be sent to them.
>> Okay. So interestingly, now, most, if it's related
to sensitive information,
most managed care organizations actually don't send an
Explanation of Benefits.
And now, they actually are not-- they're--
they used to be required to.
>> Martha, you're talking about the insurance isn't given?
>> Yeah.
>> All the insurance that they're not--
>> Yes, yes.
>> So they--
>> So they often do not send an Explanation of Benefits related
to a sensitive service visit.
It's a common misconception, at least in the State
of Massachusetts, for example,
big institutions like Blue Cross.
If a patient comes in and they have--
they get diagnosed with an STD and they get a pregnancy test.
The parents are not going to get an Explanation of Benefits.
>> So is that recent, I mean--
>> That is relatively recent.
The other thing though is that--
what's definitely been now mandated is
that if they do some Explanation of Benefits,
if it involves sensitive services,
they cannot put those codes on there.
So I'll give you an example.
A few years ago,
before insurance companies got a little bit better
about sending EOBs, so they're not sending them
as often as they were.
A few years ago, I had a patient who came in,
had a chlamydia test, it was positive.
We treated him in the office.
And he went home and he got an Explanation of Benefits
and his mom was a nurse.
And she looked at the code on there,
'cause it didn't say much.
It said lab test that did have the code for the lab test
and she looked it up in one of her books and said, what,
were you doing in a chlamydia test, and it created,
you know, all sorts of drama.
But so, the issue is that, you-- now, they cannot put on those--
it's actually mandated that they can't put
on those sensitive service codes.
Now, what they define
as a sensitive service code is a big issue.
But for instance, certainly for a lab test,
which is actually what I find to be the major issue as opposed
to diagnoses, generally, that is where it's most important.
>> Because I wouldn't do pregnant--
pregnancy test or STD test for children.
>> Correct.
Correct. They'll either not put it on which is a lot
of you EOBs are opting to do, or they'll put on just text,
without any other information and they'll put the charge
and they'll put the visit with me.
I find that parents, even if they do get an explanation
of benefits, if everything's been paid,
they don't tend to object.
>> So can you, do you have any sense Martha
of why that happened?
Why that shift happened?
>> Yes, because a lot
of organizations came together and lobbied for that.
The main organization which I'll give you the website for,
at the end, which has a summary related to EOBs,
but do you have more information that's why you're asking
or you're?
No-- yeah.
So they're-- but they're at the very end,
and I always mess up their names.
So I'll tell you at the end because it's on the slide.
But they actually came forward and lobbied for it,
and it's now mandated that they cannot put
that information on in EOB.
They can still send in EOB but they can't put
that information on there.
>> I actually saw a patient-- heard about a patient,
one of the other people in our division here.
She had done a drug screen on the patient, and mother got that
and that was not paid for, but it actually was paid for,
but it was really expensive
like 450 dollars and she had two kids.
And she said, one of them have been tested and she said
that that one wouldn't be using drugs at all.
And then there was the other one you should have been testing.
So, she was just saying I don't object
to testing but I think that--
>> You tested the wrong one?
>> We got this wrong and then she was just saying and it's
so expensive, even though it's paid for them
in an insurance company.
I know that that's driving the cost of care.
>> Yes, yes.
So when they get a summary even when it's paid for,
when they get a summary
of how much it cost, they get very upset.
I've had that actually happen with consult codes
because for some business called code as a consult,
and it can be more expensive for a visit
than a regular routine visit with their primary care doctor,
and we get calls about that.
Like, why did this cost 400 dollars,
when the regular visit will cost 250, or--
>> But now Blue Cross actually doesn't accept consults.
>> Correct, and we'll talk about that, yeah.
Not just Blue Cross, Blue Shield and the list is getting longer,
and Tufts is not accepting them.
Medicaid is not reimbursing for them.
There is actually not that many.
We will still use them.
But it's-- I think it's going be out, sorry.
>> Yeah. No.
I think what happens with us, I get a lot of calls
from the college students.
Who don't want their parents to know
that they are getting treatment for their eating disorder,
the name of our facilities can [inaudible].
So, and they have-- what I've been told
and said I can't guarantee they're not going to get it.
I would have-- I would want you to call the insurance company--
>> Correct.
>> To see--
>> Yes.
>> If they can send EOBs to you and now
to the household, is that--
>> That is something that you can do.
If you call an insurance company and say,
it's going to endanger you.
If the EOB is sent to your-- to the--
to the carrier, they will send it
to where you asked it to be sent.
If there's money owed, or things not reimbursed,
it will be sent to the carrier.
It will not be sent to the patient,
but if it's just an explanation of benefits.
There's not a bill involved.
They are not asking you for money.
They'll send it to the person who receives the care.
So, I got off in a little bit of a tangent with EOBs,
and we'll talk more about EOBs.
We'll talk more about coding.
We'll talk more about charting.
I wanted to talk a little bit more about other concerns,
other than confidentiality that prevent adolescents from coming
in the office, because part of what I wanted
to cover was just what kinds of things we can do
to make the office more welcoming to them.
And again, I welcome your comments,
and we'll keep it moving as best we can.
Obstacles to testing for chlamydia
which were well-studied in 2003, with all the fear of discovering
that they have an STD, so just not wanting
to know a fear of AIDS.
In fact, a lot of times, when I ask patients,
do you know why we ask you about *** activity?
Well, yeah, because of AIDS.
And a lot of times, that's not the top thing on my list
that I'm worried about.
So it's important I think to, not that I wanted
to spell a fear of AIDS but I wanted
to just make sure they understand what they really
should be fearing in terms of other STDs and possibility
of pregnancy or other concerns.
Some have false conceptions about what chlamydia could do.
And then other obstacles to STD care are the cost of it which,
you know, we've talked about a little bit, the transportation,
office hours, office staff.
So, if you go into the office and someone says very loudly,
"What are you here for?
Oh, you're here for chlamydia test?"
So I think it's, you know, it's important to make sure
that staff are trained, that they understand
that the teen issues need to be kept confidential
that they're maybe using code words, or they tell the patients
over the phone to use those code words, that they're very clear
on what the policy is around confidentiality, of that a lot
of people are parents themselves.
And they sort of feel like, if I were a parent,
I would want to know about this.
So they have trouble with the confidentiality policy,
and sometimes they violate it just because of the parent,
they feel conflicted about it.
Or they just feel like they're doing the right thing.
Not that they're calling up a parent,
and saying your child is here for X, Y, and Z. But they're not
as discreet in the waiting room or wherever.
So other parents overhear and things like that, you know,
the print and the office should be things that adolescents,
this is all, you know, old news to you guys,
but it really bothers me that in one of our exam rooms,
we have the alphabet with Elmo on it.
And we bring patients in there because we are pediatric
and an adolescent clinic.
And so often, at least, just point out to that
and say "I'm sorry, you're in the Elmo room today"
because we have a lot of--
we have other exam rooms that are better.
But I don't really want an adolescent sitting and looking
at the alphabet with Elmo on it.
It's very effective for the younger kids
and it gives them something to do while they wait for us.
But it's not so entertaining for our teenagers.
And I do really try to keep things,
but posted that we're friendly, and so, lesbian, gay,
transgender, and bisexually youth.
So having just, you know, the pink triangle sticker
on the cabinets or something that's posted that's clear
that you're accepting and open practice for youth
of all genders of all orientations,
and all ethnicities, et cetera.
It's really important that it's communicated.
And I think it's great to post something about confidentiality,
because I find that if they're sitting in the room.
Parents will read that and will say "Really, is that true?"
And will ask about it.
So these signs here are actually made
by the adolescent health working group,
which I think does a great job summarizing what you can do
to make your practice more adolescent-friendly.
They're an organization based in California,
and they actually provide you free tool kits.
You can download in PDF form, and it's a tool kit that kind
of guides you through office setup, questionnaires.
How to address particularly sensitive issues.
How to ask about particularly sensitive issues.
So, definitely worth looking into if you're interested.
The adolescent health working group, and website is
at the end of the talk.
Again, just making sure that the teenagers have a place
that they know is private, is really important.
We don't have after school times for teenagers.
We don't have weekends for teenagers.
I think it would be fabulous if we did.
Many of you probably do,
I hope because I think it's really important.
What do you guys do about late arrivals for teenagers?
>> I usually just see them if they're coming or not.
>> Yeah. So it's a big debate in our practice
because our pediatric patients, we generally, if they are more
than a certain amount of time late,
we generally don't see them.
We generally ask them to reschedule and come back.
But for a lot of the teenage patients, a lot of times,
they're getting rides from people,
or there's trouble coordinating things,
or sometimes they didn't want to come and the parents force them
to come, and they were late, and it really need to be seen.
And so, if I tell them to come back, they might not come back.
And so it's kind of hard to get them there in the first place.
So, I generally see them, but then what I usually do is send
out a letter when someone is coming to the adolescent clinic
to say "Welcome, here's how we do things,
and one of the other things that you should know is
that you can oftentimes spend a long time in adolescent clinic."
It takes a long time to talk to teenagers and sometimes you have
to wait, and it actually really helps people kind of be aware
that oh I might wait for an hour.
Let's bring our homework, let's bring some reading material.
Make sure you have a cellphone to play on.
It makes a big difference
that they know what to expect coming in.
In terms of communicating, do you have a system
for communicating with your teenage patients now?
>> I'm going to question about this because it's kind
of [inaudible] and there's a huge debate about can you text,
can you email, is it okay, is it HIPAA?
And, I don't -have an answer
>> So yeah.
So that's a good question.
So in terms of email, it depends
on if you have a secure email system,
then it's technically not okay to email.
That thing said, I email unless you have a secure email system.
With that being said, I do email other providers
about my patients, and we just use initials for their name
because otherwise, we would have a hard time keeping
up when you have an eating disorder patient
that has a nutritionist, and a caseworker at CDC
and a therapist, and a psychiatrist sometimes,
and a family therapist having an email communication,
I think really improves the quality of their care.
And we do have secure email,
although not all the email addresses
that I'm using aren't particularly secure.
So I'm very careful about what information that I share.
And so technically in terms of HIPAA,
if you're not sharing any personal health information,
so you're not sharing their date of birth,
you're not giving their name, their address.
You're not giving their social security number, you know,
I think you could argue that you can share that,
that you can have those e-mail exchanges.
But don't quote me on that, that's--
we need to ask the HIPAA lawyer for sure,
but that's my very basic understanding of that.
In terms of texting, a lot of places are doing it.
There's actually a couple of websites
that have information about it.
One is called texting in the city,
and another one is called mobile health.
And so there are various organizations
that are doing work with this.
We're not allowed to text in my organization,
it's not considered secure.
In terms of appointment reminders, what do people do
for appointment reminders for adolescents?
Do you guys call and remind them?
And when you do who do you call?
>> You call the house, there's a system that they call,
a couple of days before, right?
>> Yeah, we used to not do this at all except
for routine health visits [inaudible], but there were
so many no shows and so in an nonpopulation, it was decided
that you can simply call and say we have an appointment.
>> Mm-hm.
>> So that's-- it's not complete confidentiality.
>> Right, right.
So that-- and we run into that to, we don't--
when they make an initial appointment,
we don't do a reminder call.
If they miss the appointment,
we actually notify their primary care provider,
that they miss the appointment.
Because then oftentimes it's the primary care caller is calling
as opposed to the adolescent clinic.
It's not as much of a red flag for the parents,
so we ask them to do it.
In our organization, once they come in we actually get this--
we ask for, it's a procedure that they go through,
we ask for the patient's cellphone number.
And then we ask a series of questions:
Is it okay to call your number?
Is it okay to leave a message on your number?
Is it okay to call your house with an appointment?
And those questions are posted in a particular section
of the electronic medical records so,
whoever is doing the call backs, accesses that and calls.
If you have an automated system, that gets more complicated,
and we do have an automated system
but our adolescents don't get put into the automated system,
we have someone who does it by hand.
>> Do you just see consults?
[inaudible]
>> I don't-- not in adolescent clinic,
I do have primary care adolescent patients,
but in our consult clinic, it's just patients who are referred
or patients of mine who are coming
for specific adolescent issues.
So predominantly, eating disorders, substance abuse,
depression and anxiety, ADHD, PCOS, lots of PCOS,
lots of reproductive health care and GYN issues.
For routine-- sorry go ahead.
>> So you can refer to yourself from--
>> No, I cannot refer to myself.
But I'll see my patients just in the clinic because we're setup.
And that way then they get tapped into some
of that more confidential services.
But I don't bill as a consult.
That I cannot do.
So I basically recommend that there be a standard way
to contact the patient, that it be documented
in a standard place in the chart,
and that all the staff is aware of it.
And it makes a huge difference,
especially with calling back results.
So we'll get my lab results electronically and I'll say:
"Please call back patient using."
Using number and fam-- we have a family section in [inaudible],
and that's where we document their cellphone number.
So the staff knows to do that.
For a while they had a problem,
if they didn't find the cellphone number
or they couldn't reach the cellphone number,
they'd start tracking down and calling all the numbers.
So we have a very angry grandmother call and say,
"Why were you trying to get a hold of me,
and what result are your talking about?"
And then they're saying, well we can't release those results
to you, 'cause they're confidential.
And she's thinking: "Oh my god, she's pregnant,
what I'm I going to do?"
It caused a lot of unrest.
So we tell people, if you can't leave a message,
just document till you can't and let the provider know,
which would be me, and if I think they need
to be contacted, I will.
But for negative chlamydia or negative test,
I'll often have the staff call, leave a message,
but on the patient cellphone.
[ Inaudible Remark ]
Yes, we've run into that a little bit.
And so if we do, the standard is:
"this is Dedham Medical calling.
Please give us a call back."
That's all we say.
We don't say, the results are, or anything like that.
Definitely that comes up.
In terms of when to start asking in terms
on the confidential questions,
when do you guys usually start asking?
Age 11, 12?
[ Inaudible Remark ]
Most of the patients I'm seeing are probably 12,
13 in terms of who get referred directly to adolescent clinic
for me, but in primary care, usually I'll start asking
when I'm seeing signs of puberty or I'll ask about kind
of what things are like in middle school?
What kids are doing?
You know, if they're very, very immature fifth grader,
I may not ask about *** activity.
But I think it is important to kind of *** the patient.
I try to encourage providers to ask on every occasion,
so if they're in urgent care, I ask them, if they're in for a,
you know, an immunization, ask them, you know, check and see,
are they due for chlamydia test?
Do they, have they had one in the last year?
There's some good studies that show that testing for chlamydia
in urgent care setting can really help reduce rates
and improve testing rates.
One of the things that I have learned is in terms
of finding alone time with the patient, I don't know
if they can read, but it says, "So would"--
actually, can I read it?
It says-- so basically, it says, "So would you like me
to tell your mother or should I that you're pregnant?"
And you have this mom sitting right on the other side
of the curtain that was hearing the whole conversation.
And I actually run into that a little bit when I ask parents
to live the room that they'll stand by the door
and they have overheard some conversations.
So now, I am in the practice of I open the door and say,
"You can have a seat in the waiting room,"
I watch them walk away and then I close the door 'cause I would
say it happens almost once one a week that they try to stay
and they're not sometimes even trying to listen,
but they can overhear.
Our walls, unfortunately, are thinner than I'd like.
I found not to even more true
in the academic study 'cause sometimes they're just
partitions or things.
So, I've definitely run in to some near misses
or some problems with parents overhearing.
And as I talked about, I definitely explain--
once the patient has left the room,
I'll definitely explain again to--
once the parent has left the room, I'll definitely again
about confidentiality and ask them again, "Do you understand.
Do you have any questions about it?"
As I said, I do send a letter ahead
of time explaining confidentiality to adolescents
and I'll also explain what adolescent clinic is like,
the wait, et cetera.
The other big thing that I really believe in is
that when I walk in the room, I focus on the adolescent.
So I walk in, I shake their hands, I say hello,
and then I turn to the parent and say, "Hi, how are you?"
And that's different from what we're used to doing
in the pediatric setting.
So, I really make a big effort to do that and encourage a lot
of the providers in the office to do that.
And then, I always try to ease in to the situation,
compliment the patient on something they're wearing
or something about them, not their size, shape,
you know, hair, whatever.
But I meant to say, "Oh, those are really neat sunglasses," or,
"Oh, what book are you reading?"
or, you know, something that kind of engages them.
Have a nice conversation with the patient
about that before I move on to the more,
you know sensitive stuff.
These are probably obvious to you in terms of things to think
about as you're asking confidential questions.
But one of the things that I wanted
to highlight is the Sandwich Method which--
are you guys familiar with that in terms of, you know?
So I'll usually, like I said, I'll say something positive,
I'll praise them for a positive risky--
you know, something that they've done that reduces their risk.
I'll talk about the risk and my concern about the risk
and then I'll praise them again.
I actually find this very effective
with eating disorder patients because, you know, they come in,
they've lost weight, they feel like they are a failure,
so we'll talk about what's been good, we'll talk about what need
to fix and then we'll talk about what's been good again.
So they leave sort of motivated and kind
of with their self-esteem up just a little bit.
We talked about what to ask and when to ask it.
Does anyone have any question about that?
I don't want to spend too much time on that.
I think you guys got that down pretty well.
In terms of communication too, I think this is preaching
to the preaching to the choir, barriers in terms
of history taking also, not something I think that most
of this audience necessarily needs to hear,
but certainly you want to make sure you're asking questions
that you feel comfortable hearing the answers to,
that you're avoiding being judgmental.
And eye contact is really important, see--
trying to determine whether the patient wants eye contact
or doesn't want eye contact.
So some patients don't want to make eye contact
and so you don't have to.
I do find that patients are actually quite used to me typing
on the computer and talking to them at the same
and that they're okay with that, although I do tell them,
"I'm just making notes so I don't forget what we talk about.
This is not, you know, an e-mail
to your friend telling them everything you're saying,"
and they think that's hilarious, and just so that they know
that this isn't just like I'm writing
down all their personal information.
If it's a really like hot topic and tends like, you know,
they're telling me they were sexually abused,
I don't usually sit and type it
in the computer while we're talking
but that's somewhat obvious.
[ Inaudible Remark ]
I used to run into that a fair amount
at Boston Medical Center too.
Yeah. And it is a hard issue.
I usually try to just address it out right
and discuss it directly with the translator
and the patient all together, you know,
"Do you know each other?"
or, "How do you know each other?"
and review confidentiality and review, it is against the law
for this person to share anything out of this room.
And if that person shares anything,
he will be fired or she will be fired.
I literally [inaudible].
[Inaudible Remark] They are.
They are.
>> But it's probably important for the patient to know about--
>> Yes. Yes, exactly.
And I have-- actually, I take care of a lot
of my colleague's children for some fairly sensitive issues,
and it is challenging.
And so I have that conservation with them too of,
"You know what, if your parent gets caught looking
in your medical record, they will be fired.
If I talk to them about things
that are confidential, I will be fired."
There are actually very strict policies at Dedham Medical
about that and many institutions
about who has access to which chart.
And if there is a breech, it actually gets written up
and publicized for the entire-- it doesn't say the individual
but the event that occurred, gets publicized
for the entire organization in an e-mail
so that everybody knows what occurred
and what the consequences were.
So, it's taken very seriously and I really make sure
to tell the patient that because I don't want them feeling
like they can't share
and I still they probably don't always share everything,
went in there, parents works there but I do hear a lot
of stuff, so I must help some.
If I hear a lot of stuff,
I wonder what I'm not hearing but-- so charting.
Do you guys run into problems
with confidential information getting released
when charts are-- yes.
So what kinds of things have you done to try
to alleviate that issue?
>> Sometimes we have a big-- when I was [inaudible] director,
we have big stand for this, confidential--
confidential did not release without permission--
>> Yes.
>> -- provided that we stand for every [inaudible].
>> Yes, yup.
>> So it's the electronic medical record,
we really don't have that [inaudible] typed
and big letters on the top of the page, confidential.
>> And you have probably those phrases that you can pre-do,
you know, so you can type in-- oh, you don't?
[Inaudible Remark]
So in our electronic medical record, you can type
in a brief code and a full statement
that you've put together,
a full phrase will be entered, it's very handy.
So I use that, I have that actually standard
that I can put on top of my charts.
And I also actually have templates, and on the top
of the templates, it says
that there's confidential information.
[Inaudible Remark] Yeah, it's--
>> Did your medical record department honor that?
>> Yes, yes, they do.
>> Are they going to go through every page and look for--
>> No, so what the-- so the way that they handle it,
and this is what I tell people you should know what the policy
is in your institution,
it varies from institution-institution and even
from individual person and the medical records,
whether they're aware of it and what do they with it.
At Boston Medical Center, for instance, they were supposed
to go through the record line by line and black
out the confidential parts, copy it and send it.
In our institution, what they do is actually similar.
They brief-- they-- if the patient is in the teenage range,
they will actually contact the provider and say,
"One of your patients, there's been medical record requested,
there is several charts
where you say there's confidential information
contained, what should we do?
Should we release the record or not release the record?"
And sometimes, I will say, "You can release pages
that don't have confidential written on them,"
or sometimes I will say, "You can release but it has to go"--
I don't want a parent taking up the record
and taking it somewhere else.
And technically, they're actually really not supposed
to be able to do that.
So I usually tell them to just send it directly to a provider
if needed if I think they need that confidential information.
If I don't think it's relevant, so I have a patient who's going
to have their scoliosis checked, but--
oh, by the way, they've had multiple Chlamydia infections
and they've requested the medical record
for some odd reasons which has actually happened
to me a few times, I don't send that.
I tell them to take that information out.
What happens for you guys?
>> We had no control over--
>> I don't give medical record [inaudible] to this [inaudible].
>> Yeah.
>> It's sensitive to this.
>> Yeah. I mean there's a-- I mean there's a--
I mean in terms of state
and federal guidelines, they should be.
So technically, they're violating HIPAA
if they release the information and, you know,
you could make a good argument about it.
[Inaudible Remark]
If they release information that's considered confidential
for the patient, technically, that's a HIPAA violation
for an adolescent who has confidential information that's
released to someone other than them, which I didn't know again
until during research from this talk 'cause I thought it was
more just the general, you know, name, address.
>> And there would be the kid is going to 16, 17-year-old
and the mother is going to go through medical record
and request a copy of the medical record, so--
>> So if you have knowledge of that, I--
so if I have a knowledge of that, I will say to the mother,
"You know, you-- the medical records are usually not released
to parents because, you know,
we always have confidential information in there
for a teenager, so it have to be released directly
to the provider or, you know, you can get,
you know, pieces of the chart."
>> But that's, in case, we know but--
>> Right, exactly.
But if you don't know, it's a problem.
[Inaudible Remark] Right.
>> In fact, they actually have
to 'cause they'll say they've made multiple request
to have the record sent to the provider
and it still hasn't happen.
>> Right.
>> And they are told you should go down stairs--
>> Right, and that and bring it yourself.
And I used to find again at Boston Medical Center,
a lot of times, the reason it hadn't been sent was
that there was confidential information in there and it was
in the big pile for someone to review
and someone hadn't gotten to it.
So, the other thing that I will sometimes do
which is time consuming, but I'll say, "You know what,
rather than getting the record, why don't I just write a letter
that summarizes," of course it's more time for us,
but sometimes I will do that so
that they have the pertinent information.
But it is a very-- you know, it a tough issue.
There-- the things that people will suggest is using
abbreviations or sort of codes that you
and your institution recognize but nobody else would.
Then again, I think that can compromise the patient's care
because people need to know that these diagnoses have occurred.
In terms of the amount of detail
that you record, this always an issue.
So, sometimes that will be charge and they'll be like "well
such and such cheated on such and such,
and then the person did this, and then the person did that,"
and they have sort of like typed in every detail.
I don't recommend doing that.
I used to because I wanted to have all that detail
so I'd remember it, but the problem is there are a lot
of people who do read that chart who are going to be judgmental
about that, or who might slip up
and say something or things like that.
So, I don't recommend necessarily including all
that information.
I might make a quick note to say there were some issues
with boyfriend and cheating or, you know, relationship problems,
but, as I said, I used to write the whole summary
but what I'm finding and, in some of the reading
that I was doing in preparing from this talk and talking
with Lydia Shrier who did a lot of the slides is
that less is better to document what you know,
but not all those details about relationship drama.
You can use a shadow chart which is what we used to do
in the days in-- at UCSF.
When I was there, you would have thought being near Silicon
Valley that we would had enough records before everybody else,
but in fact we didn't, we had a shadow chart.
>> [Inaudible] go under Jacob?
>> Yes. [Inaudible]
>> Yes.
>> -- joint commission on hospital.
>> And again, in some ways, you want--
there's certain information that all providers do need to know.
What I struggle with is what people write
in their problems lists.
So I will see people put
on the problem list high-risk *** behavior.
Well, that's different for everybody.
And so people will use that as a screening codes
that will determine which STDs they use,
but you can also just use screening
for sexually transmitted infections which is a little bit
of a gentler code than writing high-risk *** behavior
or other, you know, similar things that you can use
as a code because what happens is that you walk in the room
and the electronic record, anyway, you pull up the chart
and there's a snapshot, at least in our system,
where all their problems are listed,
and all their medicines, and da da da.
So right there looking at the nurses doing the check in
and the mom who's standing behind of the check in for the,
you know, routine checkups sees high-risk *** behavior.
And I find rather than billing in the EOBs and all that stuff,
that is how confidentiality gets violated, it's what written
on the front of the chart.
I also find that everybody has a different definition
for high-risk *** behavior.
And so, I've had providers who--
patient was young and had one *** encounter
that was considered high-risk *** behavior.
So it was written as a problem.
I saw the patient in the adolescent clinic, I saw them,
I thought, "Oh jeez, what's going on with this kid?"
And I found out she has one *** partner.
I mean I'm not thrilled
that a 14-year-old has one *** partner, but come on,
in terms of the realm of high-risk *** behavior,
this is a patient who's actually there seeking contraception,
so I don't see anything that high-risk that warrants it be
on the front of the chart.
But I use to see that at Boston Medical Center all the time
or when I was in the school-based health centers,
the nurse practitioners there would actually code using
high-risk *** behavior as their code
for screening for any STD.
And so, that's when I recommended switching it
to screening for-- it's universally going to be covered
when you use the V code for screening
for sexually transmitted infections,
so use that if you're not already which you probably are.
The other thing is that,
especially with the electronic medical records,
there are various sections in the chart
where you can put information.
So you can document it in your visit.
But if you have information that you want access to be,
you don't necessarily want anybody who opens the record
to look at, there are certain places where you can--
where you can document.
So, for instance, in Epic, we have a sociodemographic page
or social history page.
And it's just a tab that you can go to
and you can document free text, any information in there,
and it's not something that pops up, you have to go look for it
if you want that information.
So if you want something that only you can find,
there are ways in your various systems, they all have it
where you could document something
but that not everybody has to read it 'cause I--
you know, there is certain things.
For instance, a patient's orientation,
I'm not going to remember it.
I'm not going to put it in a problem list.
I'm usually going to document prefers whichever gender or both
or whatever in my note, but there are some people
who say not to do that, I do 'cause I think it's important
to know and to be sensitive, but I might forget
or I might not have documented the full scenario around it
and I want to be respectful in terms of knowing their history
and not necessarily asking them the same questions every time,
because I will, but-- then, I say, "Well, last year,
I told already," you know.
So I try to document it somewhere.
Do you guys run into issue with that it all with--
>> Well, we don't have Epic, number one-- [Multiple Speaker]
>> Yup.
>> Is there something like that
because our people have not been able to tell us about anything
like that when we get this--
>> I'm pretty sure there is.
I've definitely known people in the adolescent medicine world,
again, the private practices group,
this has come up a fair amount.
And I-- with all scripts, I'm--
there are some sections you may might not be given access to it.
So like our secretaries have access to some
of the demographic information,
there is free testing even in there.
Recently, we were given access to that.
So for instance, we can even adjust the cell phone number
in there which previously we couldn't.
>> You know, in that yellow thing in the--
[ Multiple Speakers ]
>> Yeah, the stickies are-- that's--
people call those thing the stickies, the yellow.
>> But I don't think there's unlimited space--
[Multiple Speakers]
>> And there's that something that's hidden and you have
to access it or does it come up when you open the chart?
>> It comes up.
Well, I don't know if it's hidden too.
You would have to access--
>> Yeah.
>> -- [inaudible] yellow, yellow thing that give--
it's that yellow until you populate it with something
that when it is yellow, if you put--
we put our patient contact information in there
like we put-- how they prefer to be--
>> Yeah, yeah.
>> -- contacted, their cell phone,
the name of their therapist and--
>> Right. So that is-- yes.
Yes.
>> But I don't know
that [inaudible] have enough space to allow you to do--
>> Do social information, yeah.
>> -- [inaudible] social history.
Probably, the democratic information stuff is putting the
front desk [inaudible] and they don't [inaudible].
>> Yeah. It'd be interesting to see.
You may and you don't know it and there is often a little area
that you can designate.
And as long as it's a departmental, you know,
everyone knows about it.
I've seen it work actually quite well.
And more along the lines in terms of confidentiality is kind
of getting into the billing.
So there's a couple of things to think about.
You know, you-- in terms of diagnosis and billing
for diagnosis, as I mentioned,
now most EOBs will not state the diagnosis.
But, if the patient is not insured
or temporarily their insurance has lapsed
or something comes up, where I run into problems is not so much
to EOBs, but that a bill gets sent home from our institution
with everything clearly written, what was done,
what was tested and what they owe.
And that's when I get very upset, parents,
because I'm billing them
for something they didn't even know about.
So one of the things that I do is I ask every patient
if their parents knows they're there.
And if they don't know they're there, then I--
we have a specific procedure in our institution
that prevents a bill from being sent home.
And we actually eat the cost.
But what doesn't happen is what the lab does with the billing.
And again, sometimes the lab might not have the most current
insurance information but what we do.
And so, again, the lab sends something home.
So a couple of things that I've done to help alleviate this is,
one, is I talk to a lot of parents about how it's standard
to test kids for pregnancy and standard to test kids
for STDs regardless of *** activity
that it's just part of standard of care.
So if they see a bill coming home with that, don't panic,
we do that all the time.
I do that before I've talked to the adolescent alone
and when both parents are in the room just so that they kind
of expect that, so then it's not a big surprise.
The others is you know, billing based
on symptoms rather than the diagnosis.
This is both in terms of reimbursement as well
as in terms of confidentiality.
So if they have the urethritis, I bill for dysuria.
If they have chlamydia, I bill for any sort
of symptom that's related to chlamydia.
There are times when I can't always--
if they're coming in for family planning, you can't bill
for family planning anyway, so I usually had to bill
for some menstrual irregularity or something like that.
And, you know, the part of me that doesn't like that is
that you're not giving a holy accurate diagnosis.
But I find, if I search enough,
I can usually find some sort of--
well, sometimes I have little vaginal itching.
Okay, I've documented that.
We've talked about it.
That's the diagnosis that I'm going to use.
So, it also comes up with reimbursement in terms
of mental health issues.
So I see patients for ADHD, for depression, for anxiety.
And I'll go through all the symptoms of depression
or anxiety, and rather than billing for anxiety,
I'll bill for restlessness, nervousness, fatigue,
sleep problems, any sort of symptom related
to that condition as opposed to billing as a primary diagnosis,
depression or anxiety.
And, of course, the standard
that often will get some reimbursement as opposed
to depression or anxiety is adjustment reaction
or adjustment disorder.
The other reason
that I oftentimes will use those diagnoses is
that when I have them in the problem list.
Again, I want to make sure that whatever pops
up in the problem list, I want it to be something
that I don't care who sees it.
So, you know, sometimes, you know,
people will suspect borderline personality disorder
and they'll document that in the problem-- borderline traits.
Well, then, you know, now, actually patients have access
to their problem list at home and they go and they look at it,
and they're being "What do you mean borderline traits?"
or "psychotic episode?"
You know, and they were seen in the ER
and they had some weird episode and it was called that
and the provider gets the note
and they put it in the problem list.
But, really, the patient never even knew that they had that
and it really upsets them when they see a diagnosis
or anger management issues or, you know, all sorts of things.
So I've seen a lot-- I've got--
seen a lot of patients get quite angry now that they have access
to their charts, about what's listed as their problems.
So I always tell people,
"You want to list what you would want people
to see for yourself."
So if you had depression and you want people to see depression,
that's fine but make sure it's clear to the patient
that that's their diagnosis, and also make sure that if,
you know, they have a substance abuse problem that they know
that you're documenting they have a substance problem
or whatever it may be.
In terms of parents viewing the medical records along those
lines, we have a separate login system for patients
that view the records online.
So the adolescent can view everything, the parents cannot.
And I don't know if you guys have it
where patients have access through patient portals yet.
>> No.
>> That will come up and when it comes up in terms to relation
to adolescents, it's something that we had to really or I had
to really get on our institution about giving them access
but limiting parental access and really being mindful
of what's going to appear in terms of medications,
in terms of problem list, et cetera.
With medications, if you treat them one time for Zithromax,
one of the ways to get rid of it is
to just put an expiration on it.
So then, it doesn't stay in the system.
So that's what I try to do with anything
that I don't want parents to know about.
[ Inaudible Remark ]
Yup, yup.
[ Inaudible Remark ]
I do do that sometimes.
I also, sometimes, print them and don't give them
to the patient but I've printed them.
[Inaudible Remark] That's not-- I know.
[ Inaudible Remark ]
Right.
>> So I guess what you can do, you can--
what you can do is offer to the patient and say,
"You don't want this thing
that has this sensitive information," right?
>> Yes.
>> Here's a shredder.
>> Yes.
>> I'm putting it in the shredder.
>> Yes, exactly, absolutely.
Or you can offer to the patient and say, "You can take this away
but just be aware of what's on it.
So if you don't want your parents to see it,
you should throw it in the trash or the shredder before you go,"
and tell her where the shredder is.
>> Again, that works for us or in our clinic practice
but if they're going to be going to other, especially providers
and things in the institution, that must take care of that one.
>> And that's why you're very careful about what you put
in the problem list and why you have an expiration
on your medications.
The biggest one is birth control because, obviously,
you're not going to have an expiration on that.
But how many patients do you think are on birth control
and their parents don't know?
>> Lots.
>> Lots?
>> Yeah. [Inaudible Remark]
>> Yes. But those, the parents have to know about.
So those-- they can't--
you can't treat adolescents in this state any way
without parental consent for psych meds.
So those, they would need to know about.
[Inaudible Remark] Yes.
>> We can go a little bit
over because we started a little bit late, so--
>> Yup, okay.
Thank you.
Sorry, go ahead.
At what age?
>> Up to what age?
>> 18.
>> So, under 18.
>> Parents have to consent for medications related.
They can consent to other types of psychiatric care
and mental health but for medications,
you need to parental consent for psychiatric medications.
>> So should we be giving recent information
from every adolescent for them to give permission
to their parents to be aware of?
It shows it's so different we can do them.
Family therapy, treatment plan gets signed by the parents.
They know exactly what they're going to--
>> No, I don't think you have to get consent because I think
that you've, you know, the parent--
the patient signing it-- signing the treatment plan as well
as the parents so that, you know, I think that's implied.
And in terms of psychiatric meds,
they're allowed to know about that.
So the time I do get consent is in my patients who are over 18
because technically, if parents call up
and they want information, we can't give them anything.
So I do often say as they're headed off to college
or in their-- at their 18-year visit with the adolescent alone,
I will say, "You have an option to sign on for your parents
to get information, do you want to do that or not?
And is there particular information
that you don't want to share?"
And we have a form that allows them
to check off whether they want all information shared
or whether they don't want specific information related
to STDs, et cetera, shared.
But that comes up a lot with the kids away at college
and the parents call and they want, you know,
something sent or, you know, I've had-- sorry?
[ Inaudible Remark ]
Well, so this is again probably an institutional thing.
I send them to scan and generally, they get scanned
into the chart but then it also gets documented
in a particular section on the front sheet of the patient,
like the-- what we called the snapshot.
So it says parental consent signed on X date
and the medical record fills that in so that we know that.
>> So what about-- - when you're actually--
if you are giving your patient a prescription
that they don't want their parents to know about,
I get that question a lot, "Are my parents going to find
out about this prescription to the insurance,"
I'm never really quite sure--
>> They don't get an explanation of benefits
of the prescription itself unless they're using
like express scripts or any sort of send away.
>> If they go to the pharmacy
and fill it themselves, they should be--
>> Yes. But the problem that they will run into is
that they may not want to use the pharmacy where they go
for other routine medications
because the pharmacy will have their name
and their parent's information on file.
And then birth control prescription will be ready,
they'll call home and say it's ready.
Or even I've had patients who their parents come in to pick
up a different medication, you'll see, but "Oh, I have such
and such as, you know, birth control, here you go."
Guess what?
[ Inaudible Remark ]
>> I have--
>> If you could ask the insurance company,
they can call the patient.
They can call in and say
that they do not want their prescriptions
to be printed out as--
>> Yes, That's right, that's right.
And technically, they shouldn't
because the adolescents paid the 10 dollars for the co-pay
and not the parents, so they shouldn't be claiming it anyway.
I mean, but-- you're right.
I mean, so-- but the adolescents can actually call their
insurance and, in fact, reason I put this up here--
I'm not advertising for Blue Cross, Blue Shield but they--
this is from actually Blue Cross, Blue Shield New Jersey
and they actually put out regular magazines
for their patients that discuss confidentiality
and consent on a regular basis.
And they have-- they summarized in there EOBs and what to know
about them and there was a lawsuit so they're all over it.
But they have sort-- they have laid out--
they have it on their website, too,
what patients should know about EOBs.
So sometimes, you can even just print that and give it
to the patient to say, "Here's what you need to know."
Go ahead.
>> So to release medical records to parent,
if they don't have any confidential information,
do you still need the patient's consent?
>> Under 18, no, over 18, yes.
>> Under 18, no?
>> Yes, yes, yup.
>> So it's only confidential?
>> Confidential, yeah.
So for any visit that I see, I have a standard thing that's
at the top of the visit that says,
"This is an adolescent clinic visit, there is some information
in this record that's confidential".
So those pages don't get released
without the patient consent or without consulting me
where I will say, "Well, actually,
there's no confidential information in there
because there's nothing going on."
But generally, I'll actually contact the patient myself
or have medical records contact them
or it depends on the scenario.
So in terms of just getting back to billing, basically,
the way that I think about things
with my patients is the first question I want
to know is whether they know,
whether their parents know that they're there.
If they don't know that they're there, then we talk about EOBs
and we talk about whether their parents do--
they do get a summary, EOB, which is not that likely if it's
for a confidential service.
But if they do get it, will that be okay, will they be able
to handle it, et cetera.
And if they won't, then we have a policy.
If the parents know about the visit, I do make sure then
that I just bill appropriately in terms of diagnosis although,
again, as I said, sensitive diagnosis
and testing is no longer allowed to be on EOB.
But, as I said, what I run into is
that the lab may send the bill home.
That's happened actually even at Boston Medical Center
where patients get free care
because they weren't signed up, et cetera.
So some things you-- I don't know
that you can completely prevent that.
But if the parent does not have knowledge of the visit
and I'm concerned about that, I do usually make a call
to the lab to say, "If you generate a bill and you're going
to send it home, contact me first," which generally works.
And occasionally, we've just had to eat the cost
of that particular test.
We try not to, but we do occasionally.
We probably don't have these many patients as you have
that need that, so it's probably more of an issue
for you guys than it is for me.
But it's nice that we're able to do it.
And then, as I said, I try to just make parents pretty aware
from the get-go of what going to testing we're going to do,
what kind of bills they might get,
what we're going to talk about.
And I really encourage the kids to share with their parents.
I recently had a patient who had a genital *** outbreak
and she was having a lot of pain and--
on urination and complaining to her parents about it
and they brought her in.
She was in the room with me.
I said, "Oh, this is a *** outbreak."
Well, it is very hard to then figure out how we're going
to talk to her parents about it and she and I talked
about it for a long time.
We just decided that we were going
to sit them down and tell them.
And she wanted me to tell them without her there and I said,
"That will be fine," so I sat with them and I spoke with them.
It was good because they had a chance
to process it before they went in
and then really were supportive of her and helpful.
And I think that rather than, you know, helping her make
up story, it helps to do that.
And the outcome was, you know, fairly smooth.
I've had other times when my patient absolutely won't do that
and then we say, "Oh, they just have urinary infection,
here's some medicines that will help it."
But if you have savvy person, you can always get around that.
[Inaudible Remarks] That's right, exactly.
In terms of resources as I talked about,
so the Adolescent Health Working Group has great protocols
and toolkits.
They have a behavioral health one, they have a nutrition one,
they have a *** health one, they have a consent
and confidentiality specific to California,
but it's actually got a lot of useful information in it.
The National Alliance to Advance Adolescent Health is the
organization that made the EOB change possible.
They lobbied on behalf of adolescents to change that.
NAHIC is also a great resource in terms of information
about confidentiality to educate your patients, your parents,
and yourself and also just to know, you know, when you get
that irate parents in there to know how you can kind
of back yourself up and say, "Well, actually,
I can technically do this."
The Center for Adolescent Health
and the Law is a fabulous resource.
That's Abigail English's organization, I'm sure a lot
of you know about that.
Obviously, the Society for Adolescent Health and Medicine,
they actually do have some templates
as well that are helpful.
And which I haven't really glanced at their website
until recently and they actually have a fair amount
of useful educational pieces for patients particularly
around consent and confidentiality and EOBs.
And then Healthy Teen Network is also another organization that's
done a lot in terms of consent and confidentiality and EOBs
and helping educate teenagers about how
to keep their health information confidential.
So empower the patient, I mean, they're going to on the internet
and look at these things probably more than we are even.
And that often helps, I mean, I learn things from them
and they give me ideas about how to manage
that confidentiality issue which is constant and ever changing.
What other questions, any other comments 'cause I'm--
>> It sounds like you've done a fabulous job in [inaudible]
by having that system that's pretty awesome, so.
>> We try.
Sometimes it works.
>> I think that it's extraordinary
and it was a really lovely way to end the way.
So, great job, Martha Perry.
[Applause]
>> I just--