Coordination of Care for Mental Health and Primary Care Services: Concerns, and a Solution

The Patient Protection and Affordable Care Act (PPACA) mandates increased communication between medical providers that has created significant challenges for psychiatrists, psychologists and other mental health professionals (MHPs).   In particular, use of Electronic Health Records (EHRs) raises concerns about the potential unrestricted flow of Protected Health Information (PHI) about mental health services among the patient’s medical professionals.

EHRs are mandated to have interoperability - to be able to transmit PHI from one EHR to another EHR.  Interoperability is currently limited, or aspirational, for most EHRs. As EHR providers overcome technical problems it will be increasingly common for mental health PHI to be available to other medical providers.  For MHPs, this raises significant concerns about who will have access to sensitive mental health PHI, and what they will do with it.  As a result, many MHPs in Minnesota have refused to adopt EHRs.  This raises concerns for physicians about whether they have access to complete information about their patients.

Here are a few crucial concepts that are necessary to understand mental health privacy concerns for coordination of care, and possible options:

  • Pushing digital information: This is a secure sending of information between two known entities with an established business relationship, such as a primary care provider and a specialist. These types of transactions typically relate to routine workflow and processes. A non-health care example of a push transaction would be sending an email.
  • Pulling digital information: This is a secure accessing of information that involves a query and a response. The query is the request for information about a patient, and the response is the retrieval of clinical information on the patient or information on where the clinical data can be found. For example, conducting a Google web search is a non-health care example of a pull transaction.
  • EHR coordination of care option #1 - Health Information Exchange (HIE): a service that provides digital access to a consolidated patient record. The record is a collection of documents about the patient collected from the patient’s medical professionals and health care systems.  This information is aggregated and may be accessed by any medical professional or health care system staff that the patient has authorized to have access to the patient’s records. The patient does not, however, have control over who sees what is in their digital medical record.
  • EHR coordination of care option #2 - Direct Secure Messaging (DSM): DSM is a secure messaging system that was specifically designed to securely exchange PHI.  DSM may be viewed as a sort of email system for exchanging encrypted messages for coordination of care, including coordinating care but also other communications in medical systems and managed care organizations, such as making referrals. DSM is specifically designed to allow the patient to decide who receives their information.
  • Healthcare Information Service Providers (HISPs) manage the exchange of DSM messages.  HISPs maintain a directory of registered DSM users for their system, and may be able to access a national database of DSM users to facilitate broad exchange of PHI.  HISPs are responsible for ensuring that:
    •  the sender is who they say they are
    •  the message is encrypted
    •  the recipient is who they say they are
    • the recipient is able to receive the message and have it decrypted so that it is usable to the recipient. 

HIE, pros and cons

Information in HIE databases may be collected by having it pushed into the system, such as when an EHR is programmed to automatically send a progress note or other PHI documents to the HIE.  HIEs may also be programmed to automatically pull information from authorized sources into the HIE system. Theoretically, the latter function would help ensure that the patient’s digital health record is complete. Sources of information may have different privacy controls.  Aggregated HIE information, however, may result in others having access to PHI in unexpected ways, or in ways that the patient has not intended to authorize – the source of major concerns for MHPs and their patients.

For example, patients may want one medical professional, such as their PCP, to have access to their mental health PHI, but may also prefer that another provider, such as their cardiologist, not have access to this information.   Or, patients may want their medical professionals to have access to some of their mental health PHI, such as an intake summary, interim treatment summary, or discharge summary. They may not, however, want to authorize access to other parts of their PHI, such as psychological testing raw data, progress notes, psychosexual assessments, and marital therapy sessions.  With HIEs, the patient is unable to control access to their PHI.

DSM/DIRECT, pros and cons

DSM allows patients to selectively authorize what PHI is sent, and who is to receive it. The technology for doing all of this relies on HISPs, and is mature and works reliably.  The main challenge for DSM is that it is a relatively new service. Medical professionals using DSM Company A may want to send information to other medical professionals who are not registered with Company A.  The prospective recipient may be registered with DSM Company B, and therefore the recipient would be a trusted user for B, but not A.  Or, the recipient may not be a DSM user. 

According to the, utilization of DSM services is increasing rapidly:

  • The number of healthcare organizations serviced by DSM HISPs has increased from 667 in 2013 to 52,241 in 2015
  • The number of DSM “trusted addresses” has increased from 8,723 in 2013 to 1,099,484 in 2015.
  • The number of DSM transactions has increased from 122,842 in 2013 to 67,227,936 in 2015.

Today, many MHP websites include the office fax number to facilitate coordination of care. In the future, websites are likely to include information about whether the office has DSM capability.  Or, just as it is often necessary to call a recipient’s office to find out their fax number, it will be possible to call the office to find out the recipient’s DSM status and access information.


  • With DSM, patients can trust that they have control over what PHI is sent to who.
  • DSM technology is a better match for mental health services than HIE technology. 
  • Use of DSM is increasing rapidly.
  • As more medical professionals, including MHPs, register with DSM companies, DSM will become increasingly easy to use.
  • DSM is likely to be increasingly required by major medical and MCO systems in order to coordinate care in compliance with PPACA, and also to receive referrals and participate in the care of patients who are members of the system.
  • ACOs are also increasingly likely to require participating professionals to have the capability to coordinate care in compliance with PPACA.

This is a shortened version of an article originally published in The National Psychologist, (September/ October 2016 issue), Vol. 25, No. 5., Page 11.

Richard Sethre, Psy.D., is in independent practice in Golden Valley, Minnesota and blogs regularly about mental health practice issues and solutions.  More info is available at


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