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Break the Glass

Break the Glass - Departments & Programs, UW Hospital and Clinics, Compliance, Privacy

Focus

Break the Glass (BTG) is a tool in Health Link that requires users to enter a password and provide a reason before gaining access to a patient’s behavioral health information. This tool was implemented in 2011. When Wisconsin law changed in 2014 to ease restrictions on access to behavioral health records, it cleared the way for removal of BTG.

With removal of BTG, clinicians will gain a fuller picture of patient care information, which will improve patient safety and care coordination, and contribute to improved outcomes.

Removal of BTG lifts current restrictions on behavioral health information associated with:

Patient records from AODA (Alcohol and Other Drug Abuse) specialists are maintained separately under federal guidelines; the changes to BTG will not affect how these records are protected. Standard auditing practices in Health Link remain in place; and compliance education will continue to emphasize the obligation to respect the confidentiality of all patient records.

Read a recent News Bytes article announcing the plans to remove Break the Glass.

If you have any questions about BTG, please email publicaffairs@uwhealth.org with BTG in the subject line.

FAQ

What is Break the Glass (BTG)?

Break The Glass (BTG) is a Health Link tool that provides additional protection for certain types of patient records, including behavioral health records. The BTG tool requires the user to “break the glass” by providing a password and verifying the reason for accessing a patient’s behavioral health record. Because of the configuration of Health Link, BTG has also made some behavioral health records completely inaccessible even to other behavioral health staff depending on their role. Although BTG was not intended to restrict access to patients’ health information when needed for treatment or other legitimate purposes, it has at times served as a barrier.

How is BTG currently used in the Behavioral Health context?

Health Link users with a legitimate clinical or business reason to view behavioral health information can break the glass to access those records. However, even after a Health Link user has broken the glass, they may still not be able to access all of a patient’s behavioral health information because some information such as inpatient behavioral health records may not be visible to some staff members depending on their roles.

Why is BTG changing?

In 2014, Wisconsin law, which had imposed greater restrictions than HIPAA on uses and disclosures of behavioral health records, changed. The new law allows health care providers to use and disclose behavioral health records for purposes of treatment, payment, and health care operations so long as those uses and disclosures are consistent with the HIPAA requirements that apply to all patient information. This change removes the barriers to coordinating care for behavioral health patients. A UW Health workgroup studied BTG use at UW Health and benchmarked it against that of other health care organizations in Wisconsin. Many others, including Aurora Health Care, Gundersen Health System, and Froedtert are also discontinuing use of BTG.

Does this change related to behavioral health records apply to alcohol and other drug abuse (AODA) records too?

No. The removal of BTG for behavioral health records will not change how AODA records are protected. Federal and state laws still require enhanced protections for AODA records. Therefore, AODA records must still be kept separate from the rest of the medical record.

As a Primary Care Physician (PCP), should I avoid documenting Alcohol and Other Drug Abuse (AODA) issues in the history section, progress note or problem list, since AODA treatment records still need to stay hidden in Health Link?

AODA information can still be documented in notes from primary care or other specialties, just as it has in the past. This is still important clinical information that has a place in the medical record. Federal laws that limit access to AODA records ONLY apply to AODA specialty clinics or AODA specialists in certain other settings.

What will be the benefits of removing BTG?

Staff involved in a patient’s care will now have access to a patient’s health information, including behavioral health information, without the need to break the glass. We anticipate that this change will improve patient safety, care coordination and contribute to improved outcomes.

Will removing BTG place the confidentiality of behavioral health records at risk?

We do not believe that this change will place the confidentiality of behavioral health records at risk. These records will still be subject to the same strict confidentiality requirements that apply to ALL patient health information. The removal of BTG provides us with the opportunity to remind everyone that ALL patient information is confidential and should be accessed only when necessary to provide quality care (or for payment and health care operations). All other Health Link auditing practices will remain in place, and compliance education will continue to emphasize our obligation to respect the confidentiality of all health care records.

What about behavioral health information in Health Link related applications such as Care Link and Care Everywhere?

UW Health’s behavioral health information will no longer be excluded from Care Everywhere or Care Link. When an outside health care provider accesses the record of a UW Health patient through Care Everywhere or Care Link the patient’s behavioral health information will be visible.

What is the distinction between mental health records and psychotherapy notes?

The HIPAA Privacy Rule defines psychotherapy notes as “notes recorded…by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record.”

According to guidance published by the Department of Health and Human Services, psychotherapy notes are kept separate from the rest of the patient’s medical record. They are personal notes recorded by the therapist that often contain particularly sensitive information and that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes.

Is documentation in the patient’s medical record (Health Link) considered psychotherapy notes?

No, documentation in the patient’s medical record is not considered a psychotherapy note. Additionally, documentation elements such as medication prescription and monitoring, counseling start and stop times, modalities and frequency of treatments, results/progress, summary of diagnosis, functional status, treatment plans and goals, symptoms and prognosis or progress are not considered part of psychotherapy notes.

Given the changes in Wisconsin law, what are the guidelines for documentation of behavioral health services in the medical record?

  1. Each clinician has the option to maintain separate psychotherapy notes, not part of the electronic medical record (Health Link).
    • Remember, these are not a substitute for documentation in Health Link, but an additional option for recording sensitive information that is only for the clinician’s use!
    • The use of psychotherapy notes is at the discretion of all clinicians, where keeping process notes may be pertinent to ongoing treatment/care. These notes are not accessible to the patient.
    • Be sure to maintain the physical security of psychotherapy notes to ensure they are inaccessible to others. Contact Health Information Management or Privacy Officers if you have questions about the security of your records.
  2. Initial evaluations, consultations, or progress notes entered in the health record (Health Link) may be viewed by UW Health personnel, and ultimately your patient. PLEASE UTILIZE APPROPRIATE DISCRETION, FOLLOWING THE GENERAL GUIDELINE: AM I OKAY WITH THE PATIENT READING MY NOTE?
  3. Behavioral health templates currently exist within the Psychiatry Department for both inpatient and outpatient initial evaluations and continued progress notes. It is recommended that clinicians utilize these forms in an effort to standardize clinical progress notations.
  4. Whenever possible, limit behavioral health documentation to:
    • Templated or structured information as provided in the psychiatric or behavioral health services initial evaluation forms
    • Templated or structured information as provided in the psychiatric or behavioral health services progress note forms
    • While it is not necessary to utilize these forms, they serve as “content” sources for your documentation
  5. Standard auditing practices in Health Link will remain in place. Compliance education will continue to emphasize the obligation to respect the confidentiality of ALL patient records.

Will I be able to see a patient’s upcoming behavioral health appointments? And should I acknowledge them or not mention them?

You will be able to see past and future appointments scheduled in behavioral health, and should treat them with the same level of confidentiality you afford to all appointments. It’s good to remember that behavioral health issues are discussed and treated in primary care as well as other specialty clinics.

What are some other key points of reassurance I can emphasize with patients?

If a patient asks: I heard something about access to my behavioral health records changing. What is the change and what is the reason for it?

Wisconsin law recently changed to allow health care providers to use and disclose behavioral health records for purposes of treatment, payment, and health care operations so long as those uses and disclosures are consistent with the HIPAA requirements that protect all patient information. This change removes barriers to coordination of care for those receiving behavioral health care services. It now allows your behavioral health providers to share health information with other members of your health care team. This is important because it allows all of the people caring for you to have all of the information they need about your health so they can provide you with the best care possible. The confidentiality of all patient health information is protected under HIPAA. That law hasn’t changed and those strict requirements are still in place. UW Health’s standard policies and practices regarding protecting patient confidentiality remain firmly in place with training, auditing and monitoring, and disciplinary procedures to help ensure appropriate access.

If a patient asks: Who may access my behavioral health records? Why would anyone other than my behavioral health clinician need to see my behavioral health records?

Those involved in a patient’s care, including physicians, advance practice providers and clinical staff may access behavioral health information when necessary and appropriate during the delivery of care. Access to comprehensive information on a patient’s overall health improves patient safety, care coordination and contributes to improved outcomes. For example, if someone needs to access care at an Emergency Department it’s important to understand all of the medications a patient is taking and the various health conditions for which he or she is receiving care. UW Health may also share information as necessary for purposes of payment and health care operations, and as otherwise permitted by state and federal law.

If a patient asks: What level of detail can staff see in my behavioral health records – appointments, medications, hospitalizations, etc.?

Everything that has been documented in our electronic health record system is viewable to those with an appropriate need to do so. More comprehensive patient information is linked to improved care and outcomes. This is one of the many benefits of the electronic health record system.

If a patient asks: Can I request that you limit what you use or share from my behavioral health records?

Federal law allows patients to ask UW Health to limit the ways it uses or shares certain health information for treatment, payment or health care operations. The UW Health Notice of Privacy Practices addresses this question and explains that we are not required to agree to the request, except in limited circumstances.

If a patient asks: What are my rights when it comes to my health record?

Information about your rights and UW Health’s responsibilities is in our Notice of Privacy Practices. Here is a copy of UW Health’s Notice of Privacy Practices that describes your rights. We also have a summary of the Notice of Privacy Practices, which is a shorter document that also describes your rights.

If a patient asks: I’m displeased to learn that my behavioral health records are viewable by anyone other than my behavioral health provider. Who can I talk to about this?

We understand that you might have concerns, but please know that our commitment to protecting the confidentiality of your medical record has not changed. Your right to privacy is important to us. State and federal laws and our high ethical standards require that we maintain the confidentiality of patients’ health information and they limit the ways we can use and share that information. If you would like to discuss your privacy rights further, we invite you to contact our Patient Relations or Patient Resources Representatives. I can provide you with a copy of UW Health Notice of Privacy Practices. And here is contact information for Patient Relations and Patient Resources:

UW Hospital and Clinics – Patient Relations Department
600 Highland Avenue G7/210
Madison WI, 53792-2460
(608) 263-8009
patientrelations@uwhealth.org

UW Health Clinics – Patient Resources
7974 UW Health Court
Middleton, WI 53562
(608) 821-4819
patient.resources@uwmf.wisc.edu

Can patients request a break the glass level of confidentiality on a case-by-case basis? For example, if they have concerns about their confidentiality.

A UW Health workgroup studied Break The Glass (BTG) use at UW Health and benchmarked it against that of other health care organizations in Wisconsin. After careful consideration, UW Health decided to remove the barriers to coordinating care for behavioral health patients by discontinuing the use of the BTG tool for behavioral health records. UW Health does not offer BTG on a case-by-case basis. We understand that some patients might have concerns about the confidentiality of their health care information and we want patients to know that UW Health is committed to protecting the confidentiality of its patients’ medical records. If a patient wants to discuss his or her concerns about medical record confidentiality, the patient may contact UW Health Patient Relations or Patient Resources. Below is the contact information for Patient Relations and Patient Resources:

UW Hospital and Clinics – Patient Relations Department
600 Highland Avenue G7/210
Madison WI, 53792-2460
(608) 263-8009
patientrelations@uwhealth.org

UW Health Clinics – Patient Resources
7974 UW Health Court
Middleton, WI 53562
(608) 821-4819
patient.resources@uwmf.wisc.edu

Patients have the right under federal law to ask UW Health to limit the ways it uses or shares certain health information for treatment, payment or health care operations. The UW Health Notice of Privacy Practices addresses this right and also explains that the law does not require UW Health to agree to the request, except in limited circumstances. Click here for a copy of the Notice of Privacy Practices. If a patient wants to request restrictions on UW Health’s use and disclosure of certain health information for treatment, payment or health care operations, the patient may contact the Health Information Management Team at (608) 263-6030, between 8am-5pm, Monday through Friday to make the request.

When a patient is signing the Notice of Privacy Practices form, is it only required to give the patient the summary and have the full packet available, if needed?

UW Health asks patients to sign an Acknowledgment of Notice of Privacy Practices to document the patient’s receipt of UW Health’s Notice of Privacy Practices. We recommend that you give the patient the full version of the Notice of Privacy Practices. Click here for a link to the full version. The full version of the Notice of Privacy Practices is a relatively short document, it is easy to understand and is likely to answer most of the questions a patient might have about UW Health’s use and disclosure of protected health information. Therefore, we recommend that patients receive the full version of the Notice of Privacy Practices.

Resources

UW Health HIPAA Notice of Privacy Practices (Full)

UW Health Notice of Privacy Practices (Summary)