PC2065: Maintaining Adolescent Confidentiality in the 21st Century

Background: Within adolescent primary care (PC), maintaining confidentiality is important for patients’ health and well-being, as it facilitates open dialogue regarding sensitive health topics, leading to increased access to care. While state and federal laws provide privacy protections for minors under certain circumstances, the information blocking provisions of the 21st Century Cures Act (21CCA) Final Rule introduce new challenges in maintaining adolescent confidentiality. Parents now have access to most medical documentation for their child, including a provider’s clinical notes. Providers can withhold notes under privacy or harm exemptions; however, to protect adolescent privacy, some providers may block an entire note when only a portion contains sensitive information.

As pediatricians are tasked with providing various services for adolescents that may be confidential, including mental and reproductive health, and evaluation for substance abuse, there is a high risk of inadvertent disclosure of this information to parents through shared clinical notes. Electronic health records (EHRs) should allow providers to efficiently document sensitive health topics while simultaneously preserving confidentiality and avoiding information blocking.

Methods: The PC informatics team at a quaternary children’s hospital leveraged EHR functionality to conduct depression and suicide screenings electronically, present this data to providers within their documentation workflow, facilitate provider review of confidential health topics including sexual and social history, and improve patient safety by increasing the visibility of positive screens.

To preserve confidentiality, adolescent patients performed depression screening on tablets when separated from caregivers during rooming. Positive screens generated a pop-up alert for physicians and clinic staff, as well as an alert on the clinician’s schedule. Screening scores were embedded automatically within note templates, visually highlighting them if positive, without disclosing sensitive details within the note (Figure 1).

Additionally, note templates provided links to access sexual history documentation tools without having to change screens, thereby allowing providers to review and update this information outside of the note (Figure 1).

Results: When the 21CCA information blocking provisions took effect, the percentage of blocked notes initially rose, presumably from physicians prioritizing confidentiality over compliance. This percentage subsequently decreased after mandatory provider education on how to minimize information blocking by using the EHR tools. This decrease (7.3% vs 4.4%) occurred despite an increasing overall volume of notes during the intervention period (Figure 2).

Additionally, prior to the increased visibility of positive depression screening results to providers and staff, three missed positive screens resulted in patient safety events. Following implementation, there were no reported missed positive screens.

Conclusion: PC for adolescents requires a careful balance of compliance with existing privacy laws and the 21CCA information blocking regulations. By leveraging features of the EHR, PC pediatricians can efficiently and confidentially obtain, review, document, and address sensitive health information, while remaining compliant with these regulations.