Eye on Ethics

Client Access to Electronic Records — Ethical Challenges
By Frederic G. Reamer, PhD
December 2017

Remember the days when social workers wrote clinical and social service notes by hand and stored them in file cabinets brimming with manila folders? Ideally, those files never went missing or were out of alphabetical order. Access to the files, which were under lock and key (assuming the key wasn't lost), was limited to authorized personnel. Fires and floods never destroyed these precious records.

Reality, of course, was different in many social service agencies. Many social workers have tales of woe, involving frantic searches for missing records, unauthorized access, flooded record rooms, and worse. Such was life before the digital age. Now, of course, growing numbers of agencies and independent practitioners maintain electronic records that are stored in the proverbial cloud. Social workers and other staffers can access these records using electronic access codes, keys, and passwords.

Things can still go wrong. Today's social workers may have new nightmares about hacked servers, encryption breaches, unauthorized uploads, and technological failure. All of us are aware of news headlines about stunning data ruptures. There are risks no matter which record-keeping era we prefer.

In many ways, electronic records are safer, despite the well-known risks. And the widespread use of electronic records has yielded a new form of fruit: In many settings, clients can access their records at any time of day or night; all they need is a portal, username, and password.

The Emergence of Open Notes
Many health, mental health, and social service providers have opened their notes to clients. With a nod to transparency, these professionals embrace the idea that clients have a right to view their records and that such access may enhance clients' engagement with treatment and other interventions.

One of the pioneers in this significant trend is the Beth Israel Deaconess Medical Center in Boston: "Doctors, nurses, and other clinicians write notes after an appointment or discussion with a patient. These notes summarize what they discussed, the findings, what was measured, and the treatment plan. The notes become part of a patient's medical record. When patients read their notes, it can help them better remember what was discussed during visits, take their medications as prescribed, and feel more in control of their care."

Another pioneer is the U.S. VA, which created My HealtheVet to allow VA patients digital access to their medical and social service records. My HealtheVet is an online tool that was introduced by the VA to "streamline, organize, and optimize the care of veterans, active duty soldiers, and their dependents using internet and computer technologies. My HealtheVet is a completely secure system that works as an information resource and as a personal medical tool connecting patients with their health care providers." The software provides social workers' clients with access to portions of their health records, health care information and resources, a personal health journal, wellness reminders, and secure messages.

Enabling clients to access their records is supported by the NASW Code of Ethics, which states that "social workers should provide clients with reasonable access to records concerning the clients" (standard 1.08[a]). However, NASW recognizes that clients' access to records should not be unlimited. Some clients may misunderstand information contained in their records and need assistance interpreting it. Also, records may contain confidential information concerning other parties to which clients should not have access. Given these concerns, the Code of Ethics further states the following:

"Social workers who are concerned that clients' access to their records could cause serious misunderstanding or harm to the client should provide assistance in interpreting the records and consultation with the client regarding the records. Social workers should limit clients' access to their records, or portions of their records, only in exceptional circumstances when there is compelling evidence that such access would cause serious harm to the client. Both clients' requests and the rationale for withholding some or all of the record should be documented in clients' files (standard 1.08[a]).

"When providing clients with access to their records, social workers should take steps to protect the confidentiality of other individuals identified or discussed in such records (standard 1.08[b])."

This ethics standard was written before the dawn of electronic records as we know them today. The core concepts continue to apply, however. That said, clients' access to electronic records, which is certainly consistent with NASW standards, poses new and unique ethical challenges for social workers. For example, clients who are able to access their social worker's clinical notes may choose to share them with third parties, without the social worker's knowledge or consent. In one case, a hospital-based social worker provided crisis counseling to the single mother of a child who had been rushed unconscious to the emergency department following a backyard accident. According to hospital records, the mother was "out of control" in the emergency department's waiting room and "insisted that she be allowed to be with her child when the medical team was trying to resuscitate him." The mother, who decided to read the medical record online several weeks after the accident, was upset about several statements the social worker included in her clinical notes, including a sentence that referred to the mother's "narcissistic tendencies" and "separation issues." The client shared the notes with her sister, an attorney, who also became upset. The sisters were so irate that the mother decided to file a lawsuit against the social worker and the hospital alleging defamation of character by the social worker. The mother also filed a licensing board complaint against the social worker.

Although clients have always had the right to request access to their clinical records, which traditionally have been paper records, relatively few have done so. But with the advent of online portals, clients are now more likely to review social workers' clinical entries. In fact, clients who have electronic access to their records can view them almost instantaneously on their smartphones or electronic tablets.

As a result, contemporary social workers now face challenges unknown to earlier generations of practitioners. On the one hand, increased transparency is appealing to many social workers who support clients' right to know about documentation that is relevant to their lives. This is an important form of client empowerment. In some agencies, social workers and clients word their notes together at the end of the clinical session. On the other hand, social workers now have much less control over who has access to their records. For some social workers, this is a disquieting and unbidden development.

Today's social workers thus must think differently about documentation. Those who work in settings that permit clients' online access to their records—and the numbers are increasing—must now record their notes understanding that their audience has broadened. Out of an abundance of caution, social workers should type every word assuming they will be read by clients and, possibly, others. In these settings, social workers should think very carefully about the potential implications of short notes vs. long notes and about the implications of explicit and detailed notes vs. vague notes. These are not trivial judgments. While these have always been important documentation issues, the advent of online and remote access of records by clients has increased the stakes.

Clients' access to their records using online portals may, in fact, improve the quality of documentation. It is yet another indication that the digital age has changed the nature of social work practice.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.