Good morning everyone. It's my pleasure to welcome you to the first session of the APA. I'm glad you chose to spend the first session on this Saturday morning with us. I'm Mira Bodic. I'm an assistant professor of psychiatry at Columbia University, and I also work part-time in a community mental health center in Brooklyn. It's called Memonides, and I'm joined by my colleague, Peter Steen. He's an assistant professor of psychiatry at Hofstra in New York, and he is the vice chair of quality improvement at Staten Island Hospital, part of the Northwell system. And he's going to tell you a little bit more about his work as he gets up here to introduce himself. We were supposed to be joined by two other colleagues, Dr. Nubia Chang, who is a psychiatrist working in private practice in D.C., and Dr. Ludwink Salamanca, who is an assistant professor at Columbia, and then the medical director for an electronic platform called RubiconMD, which connects primary care doctors to psychiatry specialty consults. However, both of them have had last-minute issues and have not been able to join us, but they have been very kind to record their part of the presentation so you won't be missing them, and we will field any questions you might have about their particular part. I'm hoping that this is the session where you want to be. We're going to be talking about how we're going to write our notes in this era where patients have access to them in real time, and what we're planning on helping you with today, or what we're hoping you're going to get out of this today, is to understand how the Cures Act, which is this federal law that mandates institutions to provide access to patients through their records in real time, how this law is impacting psychiatry, what might be some of the benefits of patients having access to their notes in real time, and how do we rewrite our notes or unlearn what we've learned throughout our training and rewrite our notes from a more patient-centered, patient-friendly, recovery-oriented perspective. None of us has any disclosures related to this topic, but I will say we are all extremely passionate about it, which I guess you're going to see as we go through the presentations. We're going to talk a little bit about the law. I won't go into a lot of details, but I'm happy to answer any specific questions you might have, and then spend most of this in hopefully an interactive way, more than a teaching way, talking about how do we change our language to have these notes be, again, more recovery-oriented. And then we're going to wrap up with some Q&A. And before I get into the meat of the presentation, I just want to get to know the audience a little bit. How many of you here are psychiatrists? Everyone. Okay. I thought we might have some other types of mental health providers, because I've noticed throughout doing this work that actually social workers and psychologists tend to write a lot nicer notes or friendlier notes, and patients tend to be less shocked when they read a psychotherapy note rather than when they read a psychiatric evaluation. Next question. How many of you are trainees? A couple. Okay. Welcome. How many of you are aware of the policies at your institution in terms of sharing the notes or patients having access to their notes? About half. Okay. I'm hoping that after this you'll go to your home institution and find out more about how they're going about this. Okay. So going straight into it, why should we care about the Cures Act? So I would say, at least in my training, I've graduated from residency 10 years ago, so I've been in practice for 10 years. And I would say that both in residency and throughout my practice, and sorry, keep going back. My clinical work is in the emergency room in the community mental health center, so I do primarily psychiatric evaluations and follow-ups for disposition. And I have been trained to write all of the possible reasons why somebody needs to be admitted, all of the bad things that are happening with them, all of the types of symptoms that are going to help me come up with their diagnosis and such. My notes have always been very, very focused at that. And because it's an emergency setting, I never really thought that my patients were going to read them. My interaction is the one that I have with them in real time, and I'm hoping that it's a humane one and fairly positive to the extent that emergency psychiatry can be. But I had to change my mindset completely with the advent of the Cures Act because now mental health notes, again, are shared with our patients and they're shared in real time. And I noticed this, part of why we started doing this, we started it last year at APA, is that both my colleague, Dr. Steen, and I have noticed that there's a fear among clinicians, oh, my God, my patients are going to see what I write, what's going to happen next? Is it going to impact the relationship? How is that going to go? So we decided to put this guide together to alleviate some of that fear, even in situations like emergency psychiatry. According to the law, everything must be shared with a couple of exceptions, which I'm going to cover. So if you're thinking, I'm a CL psychiatrist, I document in the medical chart, yes, your notes are going to be visible. If you're thinking discharge summary from the inpatient unit, that's going to be visible. History and physical, things that don't really apply to us, but lab reports and imaging to the extent that they do, pathology reports, all of that is going to be shared with our patients. Process notes on the inpatient unit, not just in the outpatient clinic, are shared with the patients through the patient portal. There are a couple of exceptions, things that do not apply. For those of you who are trainees, especially if your psychotherapy supervisors expect you to keep process notes of the psychotherapy sessions, those are not part of the electronic medical record and are not shared with patients. However, anything that is in the electronic medical record, even for psychotherapy, is shared. So progress notes, psychotherapy, progress notes are shared. Process notes are not. There's also another exception for any documentation that you might prepare for a reason other than providing treatment. For example, your patient has a custody case and they want you to send a summary of their records to the lawyer. That summary of the records is not being shared directly to the patient unless they want to. Let's say your patient has had difficulty engaging with treatment and you think that they're a potential danger to themselves or others and you want to apply for treatment over objection, either on the inpatient or in certain states where an outpatient mandated treatment law exists, you want to apply for mandated treatment, those things are not shared with the patient. Anything that you're required to provide for any kind of legal action is not shared with the patient. So those are the only two standard exceptions to the law that everything must be shared. The good thing is, I'll go back to the timeline. The good thing is when this law was put together, there were some provisions put in place for exceptions on a case-by-case basis and note-by-note basis. So the first two things I covered are general. No process notes ever, no documentation that you prepared for any other reasons other than treatment automatically. Those are automatically protected, quote-unquote, or not released to the patient. On a case-by-case basis or note-by-note basis, there are a couple of other exceptions, and I think the first two are the ones that apply the most to us in psychiatry. The first one is preventing harm, and I think the example that we've given the most and that we thought about the most, and my colleague Dr. Steen will tell you about this in a bit, he works in a first-episode psychosis program. So a lot of the clients that he's seeing are experiencing these very frightening symptoms for the first time. Some of them have not been given a diagnosis, but some have. So imagine, let's say, a 19-year-old college student who's starting to feel very suspicious, who's starting to hear voices, doesn't know what's real and what's not real, goes to see a psychiatrist, and next thing they know on their patient portal it says schizophrenia. And, you know, they're a college student, so they Google it, or maybe they already know what schizophrenia means, and they see that it's basically a very poor prognosis for the most part. It's something that you're going to have for the rest of your life. It's something that might impact your chances to finish college or have a life or have a job. So that experience of seeing the diagnosis of schizophrenia has, on some occasions, caused people to commit suicide or to have such extreme reactions that we might choose to use this option of preventing harm if we put something in our note that we think when the patient sees is going to affect them a lot. This is one example. Another example is, I see the wife, my colleague sees the husband, there's some conflict in the family, and it turns out that the husband has been cheating. If I put that information in the chart and the wife sees it, the impact that that might have on the relationship, on the patient, et cetera, might cause the person harm. So use your judgment, but this exception exists for these kinds of one-time situations. Obviously, for the first case, you do want to explain to your patient what a diagnosis of schizophrenia is. For the second case, you do want to explore the relationship issues and how that might play out. But on that day that you found out that information or that you put it in the chart, you can choose to block that note and not share it with your patient. The second one, which is way, way more common, is privacy exceptions. So I shared with you I work in the emergency room. A lot of times I depend on collateral. Collateral information from the family, from loved ones, from outpatient providers, et cetera. I put that collateral in the chart with the name of the person, with the phone number of the person who told me that, and then I admit the patient based on the entirety of my evaluation, but maybe there's a piece from that collateral that really tipped the balance. And now the patient sees that the mother said such and such, that the mother is afraid for their life. There's a potential impact on the mother when the patient sees that. So if I put information in the chart that I think might compromise someone, I can choose the privacy exception to block that note. The rest of the ones on this list are EMR-related, security issues, et cetera. I won't go into them. And we will have plenty of time for discussion if you have specific questions about any of these or anything else related to what should not be shared. I'll go back to this slide for a second. We are here, let me see, can you see my mouse? You can, perfect. We are here post-March 15 where we're starting to see initial real-world results from agencies that have implemented this automatic sharing of entirety of the notes. And the deadline is December 31st. So we're now in May, meaning your agencies have between now and December to either come up with the process and policy to release these notes, get their EMRs up to date, get their patient portals up to date, et cetera, or apply for a waiver. The waiver is only six months at a time. So every six months the agency has to keep justifying if they're not sharing it, why they're not sharing it. So I think it's very timely for all of you guys who are here to be learning about this and especially to be going back to your agencies if they're not sharing the information and have conversations with them of how they could do it. These are also like fees and licensing exceptions. I really won't go into that. But reading the details in the law is a lot of lawyerly speak, and it's pages and pages. So I'm sure you can find some exception there if you really don't want to share the notes. But for the most part, that's not what we're looking at today. As I was saying, we're at the time where real-world data is starting to come out, and these are some of the areas that are not clear and that require further clarification. For example, inpatient notes and specifically the timing of it. Most inpatient units, as far as I'm aware, don't allow patients access to, let's say, their own cell phone or the Internet, but some do. So they could log on to their patient portal while they are admitted. So there's a chance that they're admitted on Monday, there's a psyche file with a treatment plan put in, and on Tuesday morning when you meet with them they've read their note. So your interaction with them on the inpatient unit might be completely affected by that. Same with emergency room notes, collateral info I just mentioned, but the content, if you need to justify admitting someone, how do you write that in a way that's not going to shock, disengage, alienate, perpetuate the stigma, et cetera? The timing of release of test results. I don't know if you guys have had this experience, but I had it personally of getting my radiology report before my primary care. I had a chance to look at it and finding out that I have a fracture in my ankle that I've been walking on for the previous two weeks without knowing. So it can be an interesting process, and I'm sure there are many other ones. There are a lot of questions about children, and especially this kind of age between 12 and 18, where kids might have access to some of their information, especially 16 to 18, where they have their own patient portal and what can kids see, what can parents see, and the laws are different in different states, and happy to discuss more about that. This is a little bit about the law, and I'm going to invite my colleague to talk a little bit about the language. I'm going to be using a slide deck and skipping through some of these. This is probably basic stuff for you, this slide at least, but considering what our notes used to be used for, my undergraduate degree was in journalism, and so the first thing that you always think about is who is your audience when you're starting to write something. I'm going to be talking about the written language in our notes and give a couple principles or tips for how to write in a way where, if your patient is reading this, it won't alienate them further, won't do harm. We know that our language can have the power to do harm or to be healing. I think you all already know this. Given the work that we do, we use the spoken word a lot in our practice, and hopefully our words are healing. It's just that now that people are reading the note and it's about them, it can become awkward. Previously, our notes were for ourselves, so that we had a record and could go back and look. Our notes were for other physicians, for other team members, and then also our insurance companies are listening in, regulating bodies, and now we have the consumer of mental health. I just want to recognize that where we are with the open notes kind of has a long history. It comes from people who have been marginalized and organized in either... We see the roots in the LGBTQ movement, in women's rights movement, civil rights, people organizing and coming to this idea of nothing about us without us, and so people are really wanting to understand what is being written about them and have an input. These are some of the benefits, which I think are going to be covered a little bit later. This idea of recovery-oriented language, I just wanted to look at a definition coming from SAMHSA that recovery is a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. The emphasis here that I'm wanting to point out is that this is about individuals improving their lives. There's a component of this open note that is really including the patient in the process, and some physicians who are really embracing this movement are co-writing notes with the patient, certainly at least talking about what you're going to write about with the patient, and sometimes writing your note directly to the patient and just letting the insurance companies listen in. You can use the plan section of your note to address the patient and outline what you've talked about so that they can access it as a reference guide. Some people are putting in links to resources. So it's possible for these notes to really be a tool for the patient to kind of take control or have a lot of say in their own treatment. This is just a quote that I think highlights the way people have felt in relationship to medical care and psychiatric care. I can talk, but I may not be heard. I can make suggestions, but they may not be taken seriously. I can voice my thoughts, but they may be seen as delusions. I can recite experiences, but they may be interpreted as fantasies. To be a patient or even an ex-client is to be discounted. So this is, you know, hopefully we don't want our patients to feel this level of alienation. Just a few words about the difference between the medical model and the recovery model. The medical model focuses on what is wrong with you. Recovery model focuses on what happened to you. Medical model focuses on treatment or solving the problem versus focusing on the individual healing or achieving self-directed goals. There's more of a focus on wellness. And then the medical provider is in charge and holds the knowledge expertise versus the individual is the expert on themselves, shared decision making with the provider who have their other expertise. This, if you're not familiar, the Wellness Recovery Action Plan is an example of peer-led recovery where people have a lot of agency over their own recovery path and what it looks like. So if you're not familiar, I encourage you to look this up. So here are some of the general principles. So when you're writing, it's a good idea to use person-centered language. What this means is instead of describing someone as a something or using their diagnosis as the main signifier of who they are, instead of talking about somebody who is a schizophrenic, you would use language like this person had been diagnosed with schizophrenia. So you're shifting the responsibility for that word onto the providers and allowing the person to be at the center. Limit the use of jargon or abbreviations that may be confusing. Emphasize abilities over limitations. Convey a sense of hope and expectation for recovery. And then acknowledge when there's disagreement. As you know, we are going to disagree, for example, about a diagnosis maybe or insight. These can be challenging. But if you're talking with the patient about what you're going to be writing about, it'll be less of a surprise. That's a pretty big principle here in OpenNotes is to write about what you talk about and talk about what you write about. All right. I'm going to skip forward. So person-centered. Here's an example of a very typical what you would start with in a note. PT is a 40-year-old single Caucasian F, homeless, unemployed with schizophrenia and MDD. She presented to the ED for psychiatric evaluation. Per EMR, PT is known to be noncompliant with treatment since her last IPP admission when she was suicidal and disorganized. Pretty typical. A couple things to just point out. Using abbreviation like this can sometimes be confusing for the patient. It feels distant, cold, clinical, rather than using their name. Joan Smith is 42. Instead of with schizophrenia, a history of being diagnosed with schizophrenia. Recovery-oriented language emphasizes abilities over limitations. So an example of what might be written in the note would be she is refusing further treatment. She is noncompliant or they are refusing medication. So instead it could be written, Joan said she is managing well by using her coping skills alone. So there's a just slight shift in emphasis there towards a kind of emphasis on what the patient is doing to further their recovery. They are committed to psychotherapy and feel they are doing well without medication. So what you're doing there is just aligning with the patient in your note, right? This is stuff that we know how to do, hopefully, in our spoken language. Patient is a 42-year-old single Caucasian. This is the same example. Instead of homeless, you can talk about currently residing in shelter. So what is the situation? A lot of the language and advice here is about becoming more accurate with our language rather than using labels. Instead of unemployed, you could say previously employed or working towards employment in retail. If you know these types of details about your patient, I think this is, again, getting more accurate. Instead of be noncompliant with, prefers not taking medication. Recovery-oriented language doesn't sensationalize. So this means not using terms such as afflicted with or suffers from or is a victim of. And sometimes when we're seeing situations that are particularly dramatic, we're tempted to use this type of language or if we're in an acute care setting, an emergency room. But instead, we can use language such as is living with or experiences. She was brought in by ambulance for a psychiatric evaluation after being found psychotic and wandering in the streets. Wandering is a bit of a colorful word as opposed to walking. Wandering is kind of getting inside the patient's head and saying, I know that you really didn't know where you were going. But what's observable and what is accurate is something more along the lines of walking. Found psychotic, well, what happened? A neighbor called 911 after noticing Joan seemed confused and was walking in the middle of the street. Recovery-oriented language doesn't imply that people who recover are an anomaly. She has made an extraordinary recovery and is now employed full-time as a pharmacist. This type of language implies that recovery is rare or is something remarkable. Instead, consistent with her recovery goals, she has been employed full-time as a pharmacist. This is very subtle stuff. Phrasing I think I said this, phrasing that expresses surprise or sensationalized one's recovery implies that this is rare and it can feel patronizing. Recovery-oriented language conveys a sense of hope and expectation for recovery. Sam is high-functioning. Sam is really good at. Sam is unmotivated to find work. Sam doesn't seem ready to go back to work. Sam has not yet found anything that sparks his interest. So again, you're aligning with the patient here. And then recovery-oriented language acknowledges when there is disagreement. So patient has no insight or patient lacks insight instead could be written. Joan disagrees with the diagnosis. Joan was recently diagnosed with having a substance use disorder and is still coming to terms with the diagnosis. So just acknowledging what has been talked about in the room. And then it's free of jargon, abbreviations. Another way to approach this, some providers are actually educating patients. You can even give a handout of typical jargon or typical abbreviations that are used. And this allows them to feel like they're a part of this process again. But when possible, limiting the use of abbreviations and medical jargon is also an effective way to include the patient. So the example here, SOV does not mean shortness of breath for most patients. Clarify that people understand the information they have been given. And make sure that whatever a person's age, cultural background, and cognitive skills, they have understood what has been said. And then this one I think is a really key point. A lot of the reason why this is even a thing, the reason why people have been kind of up in arms about the medical community or psychiatrists as being cold or distant or, you know, not aligning with our patients is because there's this jarring difference between how you come across in the room, this warm, hopefully warm, caring person who's talking to the patient and really coming up with goals and helping them feel like you have consistent, positive regard for them and that you really believe that they're going to make it. And then they go read the note and it's like, oh, this is what my psychiatrist really thinks of me. Like, this is a different tone. And so trying to match that tone is an important part of what we're doing with our writing. Okay, I think we have a couple of videos. Yeah, I was going to do one of the exercises to wake up people a bit and then we'll do a video. Okay, so you heard us talking. Now we're going to hear you talking, hopefully, or at least I'm banking on that. So this is a bit cheating, meaning you already heard a little bit how to approach these, but we're hoping that we can take it a step further. Let me make this bigger so you guys can all see it. Let's see, because in full screen mode it's not as good. All right, playing with the slides a little bit. Okay, you can see the text on the right side, right? I'm also going to read it. I'm going to start by giving you examples of what's the old way of doing things. And I'm hoping you feel comfortable enough to just shout out or raise your hand and tell us alternatives. And then this blue part of the screen is covering some recommendations. This handout is from the VA. The VA has had, anybody here works at the VA, by the way? Wow, surprising. Okay, we usually have at least one person in the audience that can enlighten us a little bit more because none of us works at the VA. But the VA has had open notes for a very long time. I want to say 15 years, might even be longer. So a lot of the guidance in US comes from the VA on how to make these notes more recovery oriented. So let's start with Kylie's normal. What's another way that you could write that? It's not a quiz. I'm not evaluating you. Jump in. No history. Okay. Kylie's doing well. Anything else? He's healthy. Okay. I'm going to reveal them one by one. Let's see if this works. We'll do like a little gender reveal thingy. Kyle does not have an illness or disability. So everything you said plus, right? Like this is not a right or wrong answer. We all have different styles. Sam is mentally ill. How would you rephrase that? Okay. I'll just highlight. That's fine, but I'll take advantage now to highlight this like sensationalist words that Peter was talking about earlier. So struggling assumes that they are struggling, which maybe they are. Maybe they aren't. I don't know. Maybe. Okay. So Sam is struggling with a mental illness is one option. What else? Is diagnosed with a mental illness or X, Y, and Z? Anything else? So the major difference between Sam is and Sam is diagnosed with or struggling with is it makes Sam a person and it makes the mental illness just one part. So you might choose to use the word struggling. That's fine. But that in itself is a big difference and a big improvement, right? From just saying Sam is. Do you want to jump in, Peter? I'll just say Sam reports he is struggling is, you know, if that's what Sam is saying, absolutely put it in there. But if you're assuming that, then that's when it becomes a little bit problematic. So lives with, has a mental illness, is diagnosed with a mental illness, reports he has a mental illness or he's struggling with a mental illness. Next one. Sam is schizophrenic. Yep. Any other suggestions? That's the most obvious one. Sam is bipolar. Has a bipolar diagnosis, has been diagnosed with bipolar disorder. Sam is an anorexic. Has been diagnosed with anorexia. I know the last one is a bit confusing because it only says Sam is. So the concept is instead of is, because Sam is many things, hopefully, you know, a person, maybe a husband, a father, carpenter, you know, who knows? Sam is a person with, right? So we're making them a person, not just a diagnosis. Okay. Next line. It's getting more interesting. Sam is, Kylie is decompensating. Kylie is decompensating. Okay, so instead of decompensating, you could say he's experiencing X, Y, and Z. Okay, other options? And again, each of us has our own, have our own style. This is not supposed to be, you know, the letter of the law. So how else would you phrase this? One of the, sorry, go ahead. What they are and how it's impacting their functioning. Yes, so, yep, yep. To Peter's earlier point, actually being more accurate rather than using labels is better. So this will come up later on, but rather than saying someone's delusional, you can say someone thinks the CIA is following them. This is what they're telling you, this is what they're thinking. It's totally appropriate to write that. Us labeling it as a delusion in the HPI or subjective part of the note can be quite distressing. So instead of decompensating, we could say whatever it is that they're actually doing or not able to do, but if you just want to look at the decompensating word itself, another option might be they're having a hard time, they're having a rough time. Kylie is resistant or non-compliant with the meds. You heard a previous example from Peter on an alternative. What else? Prefers not to take, chooses not to take, does not want to take, is having difficulty with her recommended medication, etc. Kylie is, it's kind of similar to the one before, Kylie is experiencing. So instead of looking at the person, we're looking at one of the components of what's going on. Okay, this one is my favorite. Sam is manipulative. I see a lot of you smiling. What comes to mind? How else would you say that? What I think is interesting about a phrase like this is who are we talking to? Like who are we telling this to? Why do we feel the need to tell the maybe to justify to the insurance company something or alert other medical providers that this is a problem, this person? Again, it just comes back to who our audience is. From my perspective working in the ER, this would be what ends up being written when someone comes in asking for controlled substances or someone who is unhoused comes in reporting some severe symptoms that we imply are for the purposes of convincing us to admit them to the inpatient unit and such. So it's quite often present in the emergency room notes that I've seen. So how else would you write this? Any alternatives? »» You can never go wrong with saying what the patient is telling you or asking you, right. So if they're asking for benzos, if they're asking to be admitted, you can never go wrong with that. That's what they said. So documenting it is appropriate for you. It's also not going to be a surprise for them. Is there any way though to get at the core of what this statement is maybe trying to convey? »» Sam reports something, but it's inconsistent with what you're noticing? »» Something of that sort, yeah. I'll tell you what the suggestion here is. And again, this is my favorite. Sam is trying really hard to get his needs met. I know this is a bit funny, but it's actually not. Like if I were unhoused, I would go to the emergency room and say I want to kill myself because you know in New York it's cold in winter and I don't want to sleep on the street and I have no other option. Last time I went to the shelter I was beaten up or my meds were stolen or I relapsed because the person next to me offered me a hit and I have cravings and I can't resist it and such, right? So if I know that's how I'm going to get my needs met because our system is such that we don't have a safe place or a good option for housing for these folks, I want to sleep in a place that's warm and safe, like the emergency room. So I'm going to get my needs met by whatever means I find suitable. I'm not saying I agree. I'm saying that we the system kind of taught people to act this way. This is also applicable for our borderline patients because- Peter may interject, patients with borderline personality disorder. Patients with borderline personality disorder, people who have been diagnosed with borderline personality disorder. Much better. When we think of these people, we think of skills and what their skills have been like in the past and it's possible to conceptualize their behavior as skillful. It's not maybe the most advanced set of skills and going through DBT they're going to learn extra sets, but what they've been doing so far is working to some degree, and so there's a way to align with that impulse to get your needs met, to reduce your emotional suffering, whatever it may be through cutting. This is on some level skillful. Yeah. Go ahead. How do you document why you believe that the patient is trying to get his needs met as opposed to the patient actually actively having suicidal ideations? Like if you're reading this and the patient actually feels suicidal. I can take that question because this happens a lot in the ER and if anybody here who's worked in acute care settings wants to jump in, please do. I'll say that it's, there are kind of two categories of folks. Some that are really really struggling because of, let's say, the fact that they're unhoused and their situation is so disheartening and so hopeless that they really feel like life is not worth living. They might not necessarily have a plan, like I'm gonna go, you know, jump in front of the subway right now, but they don't really see an end in sight because they understand how difficult it is to get housing and they understand that there's, even if they do come to the ER, all we can give them is a night in the ER or maybe a couple of days on the inpatient unit and not really fix their situation and they're hopeless and they're really sharing this because that's the emotion that they're feeling. So I think in that situation you might determine that having them be admitted or having them stay in the emergency room is appropriate even if they don't have an active plan. There's another category of folks where I feel that they have such level of previous trauma from the system and level of distrust that they'll say yes to any kind of questions we ask that are dramatic or that might make us believe that this person is at high risk. So one of the things I learned as a resident is when I ask someone, do you have any thoughts of hurting yourself? Yes. Do you have a plan? Yes. What are you gonna do? I'm gonna jump in front of the subway. That's a common thing in New York. Are you hearing voices? Yes. Are they telling you to hurt yourself? Yes. So someone who's like saying yes to everything. My next question is, do you smell dead people in the shower? You can pick whatever outrageous thing you want that can be your thing. It's very, very unlikely that people are gonna have olfactory hallucinations of specifically dead people and specifically in the shower. So this is like my test question to see are they just saying yes to everything I ask or are they really experiencing some of these symptoms? And then the obvious answer would be also observe them, right? Like so let's say when you ask them all of these questions, they're reporting to you that they're feeling terrible but once you leave they turn on the TV and enjoy themselves, you know, watching something, chat with their neighbors, laugh, joke, etc. Like there are ways that you can try to assess if they're telling you what they're telling you for a specific purpose or because they're really experiencing that. Anybody else wants to jump in? This is a common scenario. Exactly like that. They say yes to everything I ask including, do you smell dead people in the shower? Yeah, my program director told me that when I was a second year so I just stole it from him. But you can pick whatever very outrageous thing you want to ask and kind of judge in that way. I will say though that I also document that the system sucks. I don't say sucks but I say that I have no options to offer this person in terms of housing, in terms of employment, in terms of whatever. Our hospital for example doesn't have detox rehab, doesn't have an even outpatient substance use services and such. So I do take that into consideration if I end up discharging them and I document that I don't really have options for what they need. Yes. I think it depends, some of the examples that you saw on Peter's slides, the number of words was almost the same, right? Just instead of saying Sam has schizophrenia, saying Sam is diagnosed with schizophrenia is one extra word. Explaining behaviors or symptoms does take a little bit longer, but I would hope that you do that anyway if you want to justify a diagnosis or a disposition, like just saying someone is psychotic or someone is a danger to themselves is not enough to justify an involuntary admission, let's say. You do have to say what they're actually experiencing. And I feel like a lot of issues with timing of the documentation, and again, I work in the ER, I document only psyche vials, which tend to be pretty long, is that there's a lot of redundancy. We repeat the same information in multiple, you know, like a lot of people put some of the past psych history in the one-liner, and then it goes in the past psych history section itself, and then you use some elements of that in your assessment. So learning how to not repeat the same thing multiple times makes your documentation shorter, but it still has enough elements to justify what you're trying to do. That's not really answering your question, but yeah, notes could be longer. Hopefully, EMRs are getting smarter. Hopefully, we can use dictation systems. Scribes, I don't have a clear answer to that. Yes? The best that they can share. That they can tell you, yeah. Yeah. Or overnight, or whatever. Yep. I would actually say that in New York, especially in winter, if someone can bring themselves to DR and say, I'm suicidal, keep me, rather than freeze on the park bench, that is a much, much better judgment. So, it might not be what we want to hear, but it is a much better judgment. Any other questions, comments? The manipulative one, I guess, as I was saying, is my favorite one. I will skip through a few of these, just in the interest of time, so I'll get to the bottom. Sam has insight. And these, by the way, are in the app. All of these slides are in the app. So if you want them, all of the handout is there. Sam is working hard towards the goals he has set. Again, many other similar options. Let's see if we have an interesting one on this side before we move on. Sam is high-functioning. Kylie is low-functioning. I don't want whoever wants to tackle it. well thank you you're kind of saving us by answering but I appreciate it maybe someone from the other side of the room and venture an opinion describing what they're doing yep yep and again this can be pretty brief doesn't have to be very long so Sam is really good at Kylie has a tough time taking care of herself coming Kylie has a tough time learning new things so there can be many ways in which you can describe that that don't take up a lot of space in your note how about Sam is dangerous or Sam is high-risk You can report the behaviors, tense to describe the actions, and then if you know the context, that's helpful as well. When he's upset, when he's intoxicated, when he's not taking medications. So if you know the context, that's useful. And then you can say, again, what they're actually doing. So rather than Sam is dangerous, saying Sam hits people when he's upset is actually way more helpful. It's still pretty short, and you can understand what's going on with them. Sam sometimes kicks people when he's hearing voices. So all of these contexts is super, super helpful. How about Kylie is an addict? Experiencing mental health and substance use problems. This particular section is about dual diagnosis, but yes, is diagnosed with a substance use problem, is using or misusing XYZ, whatever the substance is. And then how about unmotivated or not engaged? And that's the last one I'll torture you with for now. It's not ready to, uh-huh. I know you didn't want to go on the last one, I feel like jumping ahead, but I do think it's important for me especially. Connie's manic. All right, and then you've listed up here she has a lot of energy right now, hasn't slept in three days. So if somebody else was chosen off the chart, I would read that. I'm trying to pull it up. I'm so sorry. The concern between hypomania and mania is challenging sometimes, so it would be helpful with a manic person. It's just, that would be very challenging for me. Right, so I think for me at least, again, because I document psychiatric evaluations, it's also important where I put this information. So if, let's say, in the HPI, I say she has a lot of energy, she hasn't slept in three days, she's talking a mile a minute, she's spent $10,000 from her savings account on whatever, you know. Like if I describe those behaviors in the HPI, then in my assessment I can say that she meets five of the whatever many criteria for bipolar disorder current episode manic. Because I am going to tell her what I think her diagnosis is, and I am going to document the diagnosis, because I have to, because otherwise I can't bill for the note. I'm also going to tell her that I can't bill for the note unless I document the diagnosis. So I will put that in. I just won't put it in the HPI. I won't say Kylie is manic in the HPI. I will say she's experiencing this and this, she's doing this and this, she's saying this and this, and then that's why I have my assessment piece of it. Also, I don't know how many of you guys do this, but when you first start seeing a person, do you tell them what you're documenting and what is it for? For example, there's a part of the note where I put what you're telling me, there's a part of the note where I put this, there's a part of the note where I put a diagnosis. Just saying that, which doesn't take that long, can be super, super helpful. Even better, even better. If you can co-write, if you have that level of trust and approach with your clients, it's perfect. How would our clients know why we write what we write? How would our clients know that we have to put in a diagnosis? They don't even know that we bill, or at least not in this concept of like, I have to have these many elements of mental status, otherwise I can't bill a 99214. Not going into that level of detail, but explaining the concept behind it can be super helpful. But this gets towards some of the principles of trauma-informed as well, just letting people know, fully disclosing who you are, why you're there, what you're doing, why am I doing this, why am I writing this stuff? In my work with people who've experienced symptoms consistent with psychosis, that's how I'll phrase it as well, is that what they're reporting and what they're talking about is consistent with a psychotic episode or consistent with psychosis, and that's something that I'll also have talked with them about, and then maybe I document that we disagree. I don't know how many of you guys have had this experience in training. I was very fortunate to hear this analogy, like when you have a cold, when you have a cold, cough is one of the symptoms. When you have schizophrenia, hearing voices is one of the symptoms. A lot of people can relate that way. They require a little bit more explanation, but something of that sort, of an analogy between a very, very common medical thing as a diagnosis and then some of the components, some of the symptoms, and then how that plays out for mental health, and it's been very, very helpful. We're gonna switch to one of our presenters who couldn't be here today, Dr. Nubia Chang. She's a psychiatrist in private practice in D.C., and she works a lot with clients who have experienced trauma and has been trained in trauma-informed care and in a couple of different therapies for trauma, so she's looking at the language from the perspective of how this could be traumatizing or re-traumatizing, specifically in the medical field. I'm gonna play her video, and then we're gonna go back to some more questions and exercises. Oh, and I should say there's about a second-and-a-half delay between the sound and the... Hi, my name is Nubia. My pronouns are she, her, hers, and I'm currently presenting from the ancestral lands of the Nacotchtank peoples, now named Washington, D.C., where I practice outpatient psychiatry. Today, I'm excited to speak with you on language and psychiatry and recovery-oriented language. These are the topics I plan to cover today. It's hard to talk about language without understanding the factors that shape language, so we're gonna really go through that. And just a quick note before I start, I acknowledge that the terms used to talk about people who access mental health services are changing and evolving with time. With that in mind, I will start using the word patient while I discuss a paternalistic model and later adopt the word client and then person with lived experience. So this is a public health framework, and I'm going to be using it to sort of understand what forces sort of shape us and the language we use in institutions. So for all of us here today, our shaping begins with the interactions with our family and our intimate networks, and we're also shaped by our community and the institutions we encounter. Today, we're gonna be focused on the institution of medicine and psychiatry, which is shaped by social norms, historical forces, spirit, and landscape. Shaping is also happening for the people accessing care. Their interactions with the institution of medicine shapes them as well. Here, we wanna sort of think about does a person have to fight to get their needs met or be seen as human or worthy of respect? Or does a person get prioritized and welcomed by the institution of medicine? Different shapings there. Let's talk about the timeline of culture in medicine, and we'll kind of refer back to this image as we go. So let's take it all the way back to the start of American medicine back in the colonial era of America, and I'm specifically speaking on this because this is my practice. So at the time settlers first came to the United States, they brought with them a sort of theory of medicine. Indigenous healing modalities were looked down upon by them as they didn't fit within their medical system. Part of how colonization was justified was because settlers viewed indigenous peoples and other people of color as inferior peoples that needed to be helped. And historically, the people tasked with helping were the colonizers, who believed that their medical model was the right model. I go this far back to say as psychiatrists and clinicians working with folks who carry marginalized identities, it's really important for us to understand and be in touch with the shadow of medicine, to know that medicine is not rooted in soil that is inherently good or even neutral. And all of these historical factors shape how we practice today and the language we use as clinicians as well. Now let's fast forward to the 18th century because I only have 10 minutes, and the primary model of care at that time was medical paternalism. And at that time it was considered necessary since it was believed that only doctors could properly understand symptoms and draw useful conclusions from them. This meant that the individual history of the patient didn't matter in providing care, so the patient themselves were sort of irrelevant in the medical encounter. Now I wasn't present during this time, so I'm not sure what the culture was like really back then, but what I do know is that in our current culture today, when this model is used in psychiatric encounters, inherent in this model is a power differential between the treater and the patient that risks recreating the powerlessness experienced during trauma as the patient is left with no autonomy or choice in the situation. For many people from marginalized identities going to the doctor is already anxiety-provoking and a scary experience. Now imagine going to the doctor and experiencing the paternalistic approach. This really has the potential to further amplify distress or the difficulty people may experience while seeking care. An environment shaped by paternalism is not trauma-informed, and instead is potentially re-traumatizing. Even if unintentional, language reflecting the paternalism model is oftentimes received as disempowering, experienced as shaming or belittling, and risks being delivered in an authoritative tone or even condescending tone. You can imagine how this might feel You can imagine how this sort of culture might shape the language of medicine. Here's some examples of really normalized, though clearly problematic terms common to the medical environment. So I'm sure people have seen or heard these terms used in the workplace or seen them on notes. So moving forward to the 20th century in the interest of time, and fast-forwarding to the 21st century, where we see a shift in the culture of medicine towards recovery-oriented care and trauma-informed care. This has really led us to be more mindful of the impact of our words on others and the change really reflects advocacy efforts fighting for disability rights and patient rights so that all people accessing care are treated with dignity, respect, and can exercise meaningful autonomy. These models lead to a breakdown of the power structure upheld by paternalism through instead approaching care through meaningful collaboration. These models require us to acknowledge our responsibilities to our patients These models require us to acknowledge our responsibility in forming a collaborative environment that celebrates the person's expertise and authority in their care. You know, we still have a ways to go because the remnants of language shaped by paternalism remain in the environment and in the institution of medicine, but at least we're moving in the right direction. This leads us down a path where language promotes hope and aims to reflect unbiased descriptions of people seeking services without the burden of discriminatory undertones. Trauma-informed care is inherently empowering as the person accessing care plays a central role in their treatment team and all team members work collaboratively to support them achieve their goals. Respect is key in trauma-informed care and conveyed through sensitive use of language and respect for the person's views and, you know, empowerment, voice and choice, if you look at the six guiding principles from the CDC, safety, all of these things sort of shape language. Language that is respectful and offers hope includes person-first language, which emphasizes abilities over limitations without a disempowering or shaming undertone. Language has the power to affect the views, beliefs and actions of the writer or the speaker of the language, the reader or listener, and now with open notes, the person accessing care who is a subject of the note. So we have to be extra careful in the language we use to maintain a respectful relationship with people accessing care. Language has the power to reduce stigma and discriminatory practices in medicine. There's been sort of studies that have looked into when a person sort of sees the word addict or the word clean or dirty in a note, how they might think of the person accessing care. So people are, you know, I will put this resource at the end, but the Harm Reduction Coalition has this really beautiful PDF on language and person-first language. And they describe that people are more than their drug use and harm reduction focuses on the whole person. And some, you know, examples of the words used or seen in notes include something like meth addict. Now the term addict implies that a person is something instead of someone. And let's not use it. Manipulative, the person has another way of difficulty identifying and expressing their needs and uses indirect tactics to get their needs met. Instead of noncompliant, which literally means failing to act in accordance with a wish or command and failure or refusal to comply, that's very disempowering. So instead it's choosing not to, does not agree with. And then the word denies, we see that all the time, right? Denies this, denies that. To deny is to refuse to admit the truth or existence of something. And the term can hint at untrustworthiness. So an alternative is does not, does not experience blank. Another word, another part that, you know, I work with a lot of people experiencing disordered eating and the language around BMI is really sensitive and weight is really sensitive to them. So the term morbidly obese is commonly sort of thrown around in medicine, right? And like maybe when we're talking about people or whatnot, at least that was my experience when I was in training. And so instead of using that term in writing, we can use something like person has a BMI of blank. So here's some tips. Start outpatient encounters with questions like what drives you or what's your passion? What's important to you or who is important to you? This helps you build a holistic view of the person. This sets the stage for approaching a person with caring curiosity, and you can learn all sorts of interesting things about a person through these questions. This really will help you see them as a whole person and not a patient. Whenever I'm learning about a person's current challenges with their well-being, I'll always, always ask, how have you gotten through this? Or you went through something really dark and heavy. How did you make it through? This question helps you gain a deeper understanding of a person's strengths and resiliency factors. And it can be really helpful to always stay with the resiliency factors for a moment and honor them with the person, help them see them as well. Another thing you can do is inquire about how you might document something, especially when it's about something really sensitive. This sort of is collaborative, right? Or ask the person, how can I be sensitive to your blank or challenges with this or to your triggers around, for example, weight? And then always in treatment planning, what are your goals and how might I be able to support you in achieving that? Okay, so here are some resources. And, you know, reach out to me if you have any questions or if you'd like me to send these slides out, right? So these slides are not on the app, but our contact information is. So if you guys want them, just shoot us a notification in the APA app or directly an email to our addresses and we'll be happy to send them. Everything else is on the app, these slides are not. We have like five more minutes of another video from our other presenter, which I was going to save for the end because he talks about all of the cool ways in which open notes can help patients. But I'm wondering if we can open it for discussion for a bit. If any of you are interested, or can share or have questions about how institutions are handling this. So the first part was how can we as providers writing those notes make a difference? How can we change our behaviors? How can we change our language? But I'm wondering if we can discuss a little bit at the institutional level or if you guys have been informed starting today, my institution is going to share notes or, you know, anything along those lines. Yes. Yes. Yeah, so any entity that is licensed by Department of Health is required to share the entirety of their notes in real time free of cost, usually via some form of electronic platform or app, a patient portal, something like that, to all of the patients that they serve, and they have to share everything. So again, HPIs, progress notes, discharge summaries, lab images, pathology reports, et cetera. If you're a psychiatrist in private practice and you are not licensed by Department of Health, Office of Mental Health, or whatever the licensing institution is in your state, and most physicians in private practice are not, you're not subjected to this. So any hospital, any clinic, any nursing home, any residential treatment program, all of these things. So that's a very good question. Theoretically, yes. Practically, no. Because information is, at least according to how most of the electronic medical records work, the moment you click Submit on a note, that's how that note gets uploaded to the patient portal. So for any past notes, the patient would still have to submit a request for records through whatever process exists at that institution. So for example, at my institution, it's a written letter that they have to submit. And in the past, at least, they had to pay for printing and faxing or printing and mailing that record to them. So they had to pay a fee ahead of time for the records to be available. So, depending on how the electronic medical record works, many places have had patient portals. Many electronic medical records or many agencies have had patient portals for many years. So in the patient portal before, there used to be only like the patient-facing part of the note, right? Now because all of the information gets uploaded in the patient portal, some patient portals might have past notes. But for the most part, it's only seen from the moment that the institution complied with Cures Act, so allowed the automatic push of the notes to the patient portal, that the full information is visible to the patient. Sorry, you had your hand up earlier, right? I was just going to comment on sort of the organizational and structural level. It's interesting that our very strong recovery program in Langford is itself a terminalist impairment. So working with people with ADD or autism, they're not trying to recover from it. They're trying to find ways to make it more of a good deal of the non-neurodegenerative. I know. That's such an interesting concept. In my work, I rarely work with folks with autism, so it's very interesting that you're pointing that out. And I appreciate it. I think that there's like the definition that I shared earlier from SAMHSA. I hear you about the idea of recovery being that you are recovering from something. But I think that there's another way to look at it as just a path that you are on as a person. It's not linear. You're not going in a direction. Sometimes it's circular, takes a couple steps back, a couple steps forward. It's just a path. And the person is really in charge of what constitutes living a life in recovery. And I think, but I agree with you, it's kind of a weird, you know, the term itself has that connotation. Yes. But the problem is, we will spend, I think everybody can share, we will be more focused on documentation than talking to patients. Because people, every silly mistake sometimes we make, suppose I did not watch and check the lab today, and suppose every next week I'm coming to visit, it will be a potential problem. Why didn't you check the lab? It was uploaded, why didn't you wait like that? So it could be very simple as that, you were talking about some of the counsel, county counsel, and the hospital, you will be, and this is going to, practically we have seen, we have felt that, that we will be spending more time on documentation, and that will not be paid by the medical, or medical care, so that will be a challenge for the system, it's not sufficient for the system itself, and ultimately it's going to have an impact on the patients also. So if I spend 40 minutes with the patient, and the documentation is 10 minutes, now it will be within 5 more minutes with the patient, because I have to make sure my documentation is appropriate, and I don't be sending it to the front office. So that will be a, and we already felt that. Thank you. And I hear your concerns. I think all of us are concerned about the amount of time that we spend staring at screens rather than looking at our patients and the amount of time that we spend documenting. I'm not sure though that this in itself is going to increase the time for documentation. And again, I would hope that for me as a patient, I want to see what my therapist is writing about me. And I actually think that has enhanced the relationship rather than caused issues. And the notes are not very long, but they have helped a lot. And again, I'm going to share some of the data, like some of the research studies around the benefits of OpenNotes in a bit. One second. Somebody else had their hand up. Go ahead. Okay. Thank you. Thank you for sharing that. Yeah, this topic is near and dear to my heart. Personally, I struggle. I mean, here I am talking about this because I do really care about language, but I struggle with documentation. It's just like it's a horrible thing in our profession, in my opinion. But I will encourage you to consider, at all possible, dictation software. It's been very helpful to me. I find that even the ability to speak into the EHR somehow helps me be a little bit more in line with how I am in the encounter. It's just a little bit closer. Like, I'm describing the person the way I would describe them to themselves or to someone who cares about them. You also had your hand up in the back. Thank you. I don't know if you have any comments on that, but once, you know, we've talked about some I covered a little bit at the beginning the fact that you that this law allows the clinician to not release information on a case-by-case basis or node-by-node basis. So if there's something particularly jarring that you have not really had a chance to explore with a patient or explain to them or do some kind of psychoeducation around it like let's say a new diagnosis of schizophrenia for a college student who's experiencing psychotic symptoms then you can block that note. And I also shared earlier that I graduated residency 10 years ago so when I did my outpatient rotation we had to do treatment plans every 90 days that was the situation in New York and the patient had to sign off on the treatment plan and I was told by my supervisor to just say unable to sign. So my entire 70-something patients on my caseload at that time had their treatment plans with unable to sign, unable to sign because their treatment plans had their diagnosis and the reasoning behind the medications and all of these things and I was not trained in having those conversations with the patients and looking back now I'm horrified that I did that and I would not want to do that again. So to the extent that you build that psychoeducation at some point you can release the notes. Go ahead. I would say for me in the emergency room and Peter I'd be curious to hear in the outpatient how this feels I would say that in the emergency room there oftentimes when I won't I'll try to to preface with mom reports that this happened rather than saying patient threatened her I would say mom reports that John said this and this so I say what mom told me but I don't qualify it myself as that being true or not for any of you who might be seeing patients in the forensic system whether the allegations are against them their charges etc those are always alleged or reported we weren't there we don't know that that happened or not we can say what they told us we can say what the police told us whatever but not qualifying it I think is where the difficulty or where we could protect ourselves by not saying patient did this but rather I was told by such-and-such mom reported the police officer reported it is definitely an approach that I think a lot of people are taking which is to just shorten what you're putting in the note and limit it to just what is necessary for the purpose of what you're doing in my work I for example people are sharing a history of trauma you know similarly you're in the way that you wouldn't try to dig into it without it being kind of spontaneously there you know there's sensitivity to whether or not this information really needs to be fleshed out and whether it should be written about for them to like reread later and be triggered by and so you can use general language I think some of the guidance is that you would you know that so-and-so shared some some events that have happened to them in the past that were disturbing and you know something along those lines we had one hand up in the back and then back there go ahead yeah right so we did a similar presentation last year at APA we knew a lot less back then but this question came up so we went home and did some digging and it turns out that the laws are so different state by state in terms of what can what you can release to the parents and and what the child has can protect from the parents so I in New York is 18 in California is 12 so a 12 year old can decide what they don't want their parent to know which was fascinating to me there's some details I don't know if any of you practice in California and know more about that and can give some details but I read through and there are some exceptions concerns for safety as you mentioned but for the most part 12 and up they can protect what they want the parents to know so you would not be able to document that if the parent has access to the child's patient portal yes perfect and and it's true it's 12 and up yeah yeah yeah which was fascinating to me because in New York is a 18 I'm not a child psychiatrist but I'd see children on call and it was very it was fascinating sorry one more thing depending on how fancy your EMR is for example I don't have epic but I heard epic can do this there's a section in to your point about not remembering between visits there's a section in epic where you can document information that's not considered part of the EMR it's like provider to provider communication something of that sort but it's still it's not the epic chat per se it's another box again I don't know how it's called because I don't have a beep but that particular box does not get generated together with the rest of the note so that might be one of the places where you could document this that you can see another providers can see but not the patient go ahead you had your hand up So, I think it depends from institution to institution and I strongly encourage you all when you go back to your home institution to ask, are you sharing? What are you sharing? How does that look like? So, for example, we have all scripts. The MR that we have is all scripts. And at the bottom of the note, there's a button, there's like a checkbox that says do not release to patient. So, you can check that box and it won't release the entire note. Otherwise, once the document is generated and you look at like the list of documents let's say for a patient, it says available to patient. So, the do not release to patient, that one does not get released at any time. Like it's just, it's generated and saved elsewhere. I'm not sure if there were a legal case, let's say, if that information would be available. My inclination would be to say yes, because in a legal case, they can subpoena all the records. But otherwise, it won't be, you can't go back and uncheck that box that you already checked to block that note. At least in all scripts. So, I'm not sure how APIC or other EMRs work. Go ahead. I have a question about clinics that aren't licensed by the Department of Health. Because in particular, university student counseling centers across the country, the majority of them are under FERPA rather than DIPA. Yep. And I know like all the psychiatrists who practice in these groups still try to practice under different guidelines to kind of protect ourselves. But I'm wondering how the CUREs act. impacts those clinics? I personally don't have an answer. I know, Peter, if you do, this hasn't come up so far, so I'm going to make a note for next time. Private practice came up. So, a clinic that's in the student health center, right, because they don't bill Medicaid. They don't have to. Frequently, they're outside. Right. They're outside Department of Health. They're outside HIPAA. Yeah. Yep. I'm not sure. I would, the law is so complex. It's like, I don't know, 40, 4,300 pages or something like that. It contains many things in addition to the documentation. But there are many, there's a lot of lawyer speak and many loopholes. So they're probably not mandated to release, yeah. Psychotherapy notes are excluded unless they're process notes. So if they're process notes that you keep for yourself that are not part of the electronic medical record, those are excluded. But regular psychotherapy notes that you bill for are not excluded. Anything that you document in the electronic medical record that you bill for is automatically released unless you say otherwise. Yeah. I was hoping to show the last video, but I'm just realizing now we have only one minute. So any last questions? I can share the articles. There's a lot of data showing that if you allow people to see their notes, it improves the care. That's the gist of the five-minute video, but I can definitely share the slides. Any parting questions or comments? Yes. As far as I know so far, the APA is invested in this because they've invited us again. We did this last year and we're doing it again today. I am not sure of anything else at the APA level. I'm not sure. I'm sorry. Can you speak up a bit? I can't hear you I think you're talking about, like, talking about trauma. There is a provision, one of the reasons that you can block a note is for psychological harm. So if you wanted to include it for your own purposes and then exclude that part from being put into the portal because of psychological harm. Interestingly, I'm not sure that we mentioned it, but one of the considerations not protected, one of the reasons the law specifically says it's not allowable to block a note because you're concerned about the alliance that you have with your patient being fractured, which I think is a really interesting thing that it specifically says because in some ways you can make a case for if the alliance is fractured then the patient is harmed. But anyway, that's specifically not something that we can block the note for. I guess it's because they're trying to force us to bring these topics up for conversation with our patients. Yes. We're a little over time, but thank you all so much for joining us on a Saturday morning. We really appreciate it, and we hope you enjoy the conference. Shoot us emails for any information you want. Thank you.

Cures Act

real-time access

medical records

psychiatry

patient-centered

note-writing

stigmatizing language

patient-provider communication

administrative burdens

sensitive information

note-blocking

recovery-oriented