Margaret R. Punch, MD Michigan Medicine Patient Portal Proxy Access for Adolescents: Preserving Confidential Care While Enhancing Parent Proxy Access Patient Portals: Challenges and Opportunities Margaret R. Punch, MD Michigan Medicine

Disclosure I and my spouse/partner have no relevant relationships with commercial interests to disclose.

Learning Objectives After participating in this session the learner should be better able to: Know where to access critical information on minor consent to care. Develop a plan for expanded proxy access for parents of adolescent patients that is ethically sound, legally appropriate and technically possible.

Patient Portal Proxy Access for Adolescents Issues to allowing access for proxies of adolescent patients Why offer proxy access at all? The Michigan Medicine Journey Roadmap for change: Engaging key stakeholders Setting the stage Reviewing technical limitations Making decisions Implementation

Pitfalls of Proxy Access to Adolescent’s Health Information What is an adolescent anyway? Statutes allowing confidential care vary by state and condition and service. Age 12-14 is often start point for allowing confidential care. Who has legal access to a minor’s medical record? Parents and legal guardians. Minor patient’s right to access their own record varies by state. What is confidential care, minor consent? The legal ability of minors to consent to a range of sensitive health care services which may include reproductive health services, mental health services and alcohol and drug abuse treatment. States may allow disclosure of confidential care to parents in some circumstances. https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law

Benefits of Proxy Access to Adolescent’s Health Information Quicker (electronic) access to information for parents of “sick” kids. Trending of lab results over time More “real time” access to time sensitive test results (drug levels, chemo affected labs, etc) Access to portal features like self-scheduling, questionnaires, video visits, medication renewal requests 2 way messaging without telephone tag Vaccine Record access

Michigan Medicine Portal Journey Go Live in 2012 with Epic MyChart and Ambulatory record. Enabled full proxy access for 0-10 year olds, dropped to restricted proxy access on 11th birthday and ended on 18th birthday. Full access with proof of diminished mental capacity, ending on 18th birthday unless guardianship established. Added functionality to full proxy access over time but no changes to restricted proxy profile. 2017-increased desire to expand adolescent proxy profile from parents who aged out of full access and providers wanting to do video visits, specialty care communication and easier medication refill process.

Full Proxy Access = Patient Access Secure Messaging Medical Advice Request Rx refill Request View Letters Visit information View upcoming appointments, e check in, questionnaires Request an appointment Self-scheduling (limited) View AVS, View provider notes (coming this summer) Release of Information Medical Record Medications & Allergies Problem List Immunizations Health Maintenance Med/Surg/Fam hx Test Results Other Demographics Insurance Billing/payments (if guarantor)

Limited Proxy Access Adult to Adult or Adult to 11-17yo 2012-2017 Allergies Immunizations Demographic information Confidential Messaging Did NOT include Appointments Medication List Provider Notes (when implemented) After visit summary Test Results Rx refill request (Can use messaging)

Limited Proxy Access Adult to Adult or Adult to 11-17yo Late, 2017-present Allergies Immunizations Demographic information Confidential Messaging NOW includes Appointments in selected departments Associated visit functionality (echeck in, questionnaires) Medication List minus contraception & antibiotics Test Results minus sensitive tests Rx refill request for meds on Med List Video visits in selected departments Excluded departments: Primary care Mental Health Care School based clinics OB GYN

So how did we do it? A 3 Step, 3 Meeting Process Engage key stakeholders Three Meetings Setting the Stage Reviewing Technical Options/Limitations Making Decisions Implementation

Engage Key Stakeholders Determine and invite key stakeholders to 3 IN PERSON meetings Primary care: Pediatrics, Family Medicine, Med/Peds Specialty care Engaged stakeholders (who is asking for change?) Skeptics Those providing confidential care outside primary care Social Work, Nursing Health Information Management Legal/Compliance Technical team (EHR portal expert) Parents/Teens

Three Meeting Plan Meeting #1 Review allowable confidential care in your state Review current state portal access for patients and proxies of minors and adolescents Meeting #2 Review technical options that exist within your portal vendor in the context of desired changes Meeting #3 Review and make decisions based on information learned in Meetings 1 & 2

Implementation Plan Engage Stakeholder panel in information dissemination to the groups they represented in the process. Encourage universal support of stakeholders in the decisions made. Advertise change widely in advance of go live. In person review at departmental meetings, clinic meetings using a prepared/reviewed slide deck. Written communication channels FAQs Contact person for more specific questions

Practical Application of this Session Expanding functionality and convenience within patient portals make access for parents and legal guardians more appealing. Providers can benefit from streamlined means of communication and information sharing with portal access to parents and guardians. Statewide rules and regulations and adolescents right to confidential care do not have to be compromised to expand portal access for proxies. With key stakeholder engagement and careful planning, major changes can be designed and implemented to expand access to features and information for the parents and legal guardians of adolescents.

Questions Question: When enabling proxy access to the parent of a minor child which portal feature may need restriction? Demographics Vaccine Records Records from birth to age 10 Appointment Schedules Allergies

Answer Demographics Vaccine Records Records from birth to age 10 Appointment Schedules Allergies Explanation: Parents with legal rights would have access to demographics, vaccine records and allergies. Young minors do not have rights to confidential care. Appointment schedules for adolescents could disclose appointments the minor made on their own, therefore appointment schedules should not include appointments or departments where confidential care may be given.

Questions The parent of a 13 year old would like full access to their child’s medical information available through an on-line portal at their local health center. What considerations should be given to this request? The parent always has full rights to access the minor’s medical record. The minor patient can’t consent to their own health care under any circumstances In all 50 states in the United States there are varying statutes that allow minors to seek confidential care and that information can legally be withheld from the parent or guardian. In all 50 states in the United States 13 year olds have the right to confidential care to access contraceptive services.

Answer The parent always has full rights to access the minor’s medical record. The minor patient can’t consent to their own health care under any circumstances In all 50 states in the United States there are varying statutes that allow minors to seek confidential care and that information can legally be withheld from the parent or guardian. In all 50 states in the United States 13 year olds have the right to confidential care to access contraceptive services. Explanation: Every state allows some access to confidential care, however, that access varies based on the type of care, the age of the patient and other considerations.

Thank you! mpunch@med.umich.edu

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