Asian Social Science; Vol. 9, No. 3; 2013 ISSN 1911-2017 E.docx

Asian Social Science; Vol. 9, No. 3; 2013
ISSN 1911-2017 E-ISSN 1911-2025
Published by Canadian Center of Science and Education
154
Like It or Not: Issue of Credibility in Facebook Advertising
Azizul Yaakop1, Marhana Mohamed Anuar1 & Khatijah Omar1
1 Universiti Malaysia Terengganu, Malaysia
Correspondence: Azizul Yaakop, Universiti Malaysia
Terengganu, Malaysia. E-mail: [email protected]
Received: December 31, 2012 Accepted: January 28, 2013
Online Published: February 28, 2013
doi:10.5539/ass.v9n3p154 URL:
http://dx.doi.org/10.5539/ass.v9n3p154
Abstract
Issues like advertising credibility and privacy trust have become
the hot topics for social networking sites (SNSs)
of late. In spite of the critiques, the trend of employing SNS’s
as advertising platform by marketing practitioners
is still on the rise. This approach of adopting SNS’s probably
suits marketers’ objectives to reach and
communicate their users and potential customers with relevant

ads and personalized messages. Besides, this
approach is expected to increase the value of advertising for
both users and marketers in terms of profit and
return on investment. However, research studies on SNS’s and
how they are perceived by its users are relatively
limited, especially how online factors influence users’
perceptions and attitudes towards advertising on SNS’s.
This paper aims to examine the online factors that influence
consumers’ perceptions and attitudes towards
advertising on Facebook. A total of 350 respondents
participated in the study. The results suggest that there are
three online factors that significantly influence consumers’
attitudes towards advertising on Facebook. The
factors are perceived interactivity, advertising avoidance and
privacy. Surprisingly, credibility was not a
significant factor predicting consumer’ attitudes towards
advertising on Facebook. This paper provides some
insights to advertisers into dimensions that may draw
consumers’ favourable attitudes towards advertising on
SNS’s, especially Facebook.
Keywords: attitudes towards advertising, social networking sites
(SNS), Facebook, advertising credibility
1. Introduction
With the rapid development of information technologies
worldwide in the past decade, advertisers are
increasingly relying on various modes of interactive technology
to advertise and promote their products and
services. Furthermore, the idea of executing a content that is
current and entertaining could get consumers to
interact electronically in an effective way. This powerful
attribute can be seen as a future of advertising and may
become more figurative in consumers’ minds than television
advertising as a marketing stimulus that stands out

relative to others in their environment (Yaakop & Hemsley-
Brown, 2011).
Issues like advertising credibility, privacy trust, advertising
avoidance and interactivity have been the highlights
in most of previous research on online advertising. These issues
are imperative because they may act as barriers
or boosts in delivering effective messages to audiences and in
building awareness on the company’s offerings.
By means of social network sites such as Facebook and Twitter,
marketing practitioners have experienced a leap
in their engagement with advertising activities. For example,
click-through rate (CTR) for advertising on
Facebook is now an alternative to banner ads which has fallen
for the past over time. However, research studies
on these social network sites and how it is perceived by its
users is relatively limited and unavailable. This
statement is supported by Boyd and Ellison (2007) that stated
that there is little research published in the area of
consumer perceptions of advertising on social networking sites
although these sites faces rapid growth over a
very short period of time. Besides that, although research exists
in the area of online communications, not all of
this work is easily transferable to the social media space (Bond,
Ferraro, Luxton & Sands, 2010). Also, little is
known about how online factors influence Internet users’
attitudes toward online advertising (Campbell &
Wright, 2008). Besides that, capitals investment in online
advertising are often targeted wrongly due to lack of
knowledge and limited research done on consumers’ opinions of
online advertising which caused advertisers
chosen the wrong advertisement characteristics; sending unclear
messages; and cannot clearly identify the target
audience (Hadija, 2008). Hence, the aim of this study is to
fulfill the research gap by investigate the relationship
between user perception and their attitude on online social

networks advertising using the context of Facebook.
www.ccsenet.org/ass Asian Social Science Vol. 9, No. 3; 2013
155
2. Literature Review
A previous study by Zeng et. al (2009) found that responses to
online advertising via social network heavily
depended on perceptions of advertising relevance and value, as
well as being influenced by social identity and
group norms. Unlike, Hadija (2008) found perceived
interactivity as an important influence in consumers’
responses to the same subject. Other dimensions such as
advertising avoidance, credibility and privacy were used
in the past to measure consumers’ perceptions towards online
advertising (Kelly, 2008; Roberts, 2010).
Therefore, in congruence with the previous literature, this
research is proposing that consumers’ attitudes
towards advertising on Facebook is presented as a two-level
structure depicting generalized perception of
advertising on Facebook and the individual’s perceptions with
advertising .
2.1 Perceived Interactivity
On a personal level, interactivity is described as means for
individuals to effectively communicate with each
other, regardless of distance or time (Ha & James 1998). On a

mechanical level, interactivity is described as a
characteristic of a medium which allows for its users to
participate in creation and recreation of the content
(Steuer, 1992). Interactivity on the Internet shifts the ways in
which users perceive advertising Hadija (2008).
Since offline advertising such as television and radio are
different than online advertising, advertisers need to
analyze factors that influence consumer acceptance towards an
online advertising, which would include social
media like Facebook. According to Mangold and Faulds (2009),
social media have been acclaimed for having
influences on every stage of the consumer decision-making
process as well as influencing general opinions and
attitude formation. It is believed that high level of perceived
interactivity will incur positive and favorable
attitudes towards the advertisement on social networking sites
(SNSs).
One of the interactive capacities of Facebook is its ability to
attract users to use text, images, videos and links as
interactive content as strategies to track and share new products
with consumers. On Facebook, creating social
media profiles and updating them frequently helps improve the
general awareness and visibility of the online
business and brand. When customers are searching for
information about a company, the multilingual social
media profiles will provide information about your business,
links to your website and different information
channels that build credibility. Like other social media
websites, Facebook was created primarily to connect
people. Therefore by creating personal profiles, it allow
marketers to create company pages that can provide
direct information about the company, products and services
and have links to the website, building a social
media campaign for brand awareness.

Facebook has created a way for companies to market and sell
their products and services in a new different way.
Advertisements that appear on every page of Facebook have
enabled companies to reach potential consumers in
a way that is less time consuming and cost effective. Because of
that, companies can target users that are the
most likely to purchase their products by accessing the cookies
from the Facebook users web browser. For
example, if a Facebook user is checking the same retailer’s
website a couple times a week, their ads start to
appear on the Facebook account. Even more amazing, similar if
not the same, products that the user looks up on
that website is advertised on Facebook specifically for the user.
2.2 Advertising Avoidance
Advertising avoidance includes “all actions by media users that
differentially reduce their exposure to
advertisement content” (Speck & Elliott 1997, p. 61). Increasing
clutter and media fragmentation now expose
consumers to thousands of commercial messages every day
(Gritten 2007). A person has the ability to avoid an
advertisement by cognitive, behavioral and mechanical means
(Speck & Elliott, 1997). For example, ignoring
the advertisement on newspaper or magazine advertising is
considered a cognitive method of avoidance.
Switching to other television programs during the advertising
break is considered a behavioral method of
avoidance. And for the internet medium, deleting pop ups on the
internet is considered a mechanical method of
avoidance.
Cho and Cheon (2004) mentioned that interruption of task,
perceived clutter on internet sites and negative past
experiences with internet advertising are all antecedents
explaining avoidance of advertising on the internet.

Factors such as interruption of task happen when the speed of
data retrieval and processing in internet is reduced
or interrupted by advertising that it requires an action from the
consumer before they are able to resume their
online activity. Advertising clutter is the term given to the
perception of the consumer when they believe that
there is too much advertising within a given media at a given
time (Cho & Cheon, 2004). Negative past
experiences happens when consumers encounter unfavorable
situation such as receiving deceiving messages or
exaggerated or been forwarded to inappropriate sites.
156
2.3 Credibility
Credibility refers to the objective and subjective components of
the believability of a source or message. Media
and advertising credibility can be defined as the extent to which
the consumer believes or trusts in the media or
advertising claims (Moore & Rodgers, 2005). Findings by
Johnson and Kaye (2002) suggested that reliance on
traditional sources; political trust and convenience were the best
predictors of online media credibility. Johnson
and Kaye’s earlier study on media credibility (1998) found that
online sources were considered credible and that
younger people are more likely to view online information as
credible. The study acknowledged that even
though the internet has an unregulated flow of information and
that the quality of information was not subject to
the same scrutiny shown to traditional media; it still was

considered a more credible source of news information.
Even though online news is viewed as being credible (Johnson
& Kaye, 1998), the internet was found to be the
least credible medium to advertise in, with consumers regarding
it with the highest level of skepticism. Moore
and Rodgers (2005) found that the consumers did not feel
comfortable about surfing the online advertisements
and although as college students they fell into the demographic
that shops online the most, they still did not find
the internet advertising trustworthy. They were hesitant when
required to give credit card details or personal
information and only purchased from sites that they knew and
trusted (Moore & Rodgers, 2005).
2.4 Privacy
The online privacy debate has existed since the creation of the
Internet (Roberts, 2010). In social networking
sites (SNSs), privacy concerns has also been an issue since
users shares their information and preferences such
as their personal details, images, statuses, hobbies and so on.
Barnes (2006) stated that youth culture has
embraced online social networking and they are now publicly
sharing very personal information on these sites.
On Facebook, however, it offers an access to user information
and generates profile privacy settings in order to
overcome the concern of privacy (Ragan 2009). While privacy
policies are often criticized as difficult or time
consuming to read (Bonneau and Preibusch, 2009; McDonald
and Cranor, 2009; McDonald, Reeder, Kelley, and
Cranor, 2009), there is evidence that if a website has a privacy
policy, individuals are more likely to share
personal information with the website (Cranor et al., 2000).
2.5 Conceptual Framework

Figure 1. A conceptual framework of attitude towards
advertising on Facebook
From the Figure 1 above, this conceptual framework is
incorporating perceived interactivity, advertising
avoidance, credibility and privacy as the observed factors for
attitude towards advertising on Facebook.
A hypothesis is a tentative explanation that accounts for asset of
facts and can be tested by further investigation.
Selamat (2008) stated that hypothesis is tentative, intelligent
guesses posited for the purpose of directing one’s
thinking and action towards the solution of a problem. In this
study, the hypotheses are as follow:
H1: Perceived interactivity significantly predicts attitudes
towards the advertisement on Facebook.
H2: Advertising avoidance significantly predicts attitudes
H3: Credibility significantly predicts attitudes towards the
advertisement on Facebook.
H4: Privacy significantly predicts attitudes towards the

3. Research Methodology
Following previous literature on examining attitudes towards
advertising, students especially advertising or
marketing students were used as the sample group mainly
because they represent a major market segment,
besides frequently featuring in convenience sampling (Yang
2000). In addition, advertising and marketing
Perceived Interactivity
Advertising Avoidance
Credibility
Privacy
Attitude towards Advertising on
Facebook
157
students were among the groups commonly used to investigate
attitudes to advertising because they represent
future advertising professionals; thus, measuring their attitudes
to advertising would provide for a good start in
this research area (Andrews et al., 1991). Besides that,
university students are heavy users of communication
technologies and undergraduate students are heavy users of the

online social network site (Smith, Caruso & Kim,
2010) which means they can understand the content in Facebook
well and its functions. According to Lenhart,
Purcell, Smith and Zickuhr (2010), the use of online social
networks among teens and young adults has exploded
during the last few years and a survey estimated that in the US
72% people of the 18-29 years old are using
online social networks. Calisir (2003) also claimed that students
are most frequent users and they represent the
biggest segment in the Web usage.
In this research, the sample of the study is undergraduate
students who are currently studying the programme of
Bachelor in Management Marketing at Universiti Malaysia
Terengganu (UMT). By referring to the table by
Sekaran (2000), the total number of samples that should be
selected is 357 since the total numbers of
undergraduates in Universiti Malaysia Terengganu (UMT) is
about 5000 undergraduates taking account all
faculties in the university. A set of questionnaire is prepared in
English and the data collected was analyzed using
SPSS 17.0. The questionnaire used in this research was divided
into 2 sections and the data was collected by
means of a structured questionnaire. The questionnaire contains
24 items in section A and 3 items in section B.
Section A is about the perceptions towards advertising on
Facebook while section B is about the attitude towards
advertising on Facebook. The questionnaire for this study is
adopted based on studies from Hadija (2008) and
Kelly (2008) and are modified to the topic of this study. Gorard
(2001) assured that the advantages of using such
previous instruments and questions are considerable because the
instruments used have been piloted, used
previously, are mature and ready to be used, probably on a far
larger scale than the researcher could envisage.

4. Findings and Discussion
Questionnaires were distributed to a total of 350 respondents
that are currently studying the programme of
Bachelor of Management Marketing in the Faculty of
Management & Economics in Universiti Malaysia
Terengganu (UMT). The respondents’ demographic
characteristics are presented in Table 1.
Table 1. Respondents’ demographic characteristics
DEMOGRAPHICS FREQUENCIES PERCENTAGE (%)
Gender Male
Female
229
121
65.4
34.6
Race Malay
Chinese
Indian
Others
91

189
42
28
26.0
54.0
12.0
8.0
Age 19-21
22-24
25 and above
283
67
-
80.9
19.1
-
Year of Study 1st Year
2nd Year

3rd Year
290
42
18
82.9
12.0
5.1
Years of Using Facebook 1-3
4-6
7-9
10 and above
224
126
-
-
64.0
36.0
-

-
158
Scale purification process is of paramount importance for
assessing the reliability and validity of the
measurement scales. This process involves evidence of
theoretical content as well as validated empirical tests in
order to evaluate the quality of the data. To this point, item
analysis was carried out to ensure non-violation of
normality assumptions, reliable and valid prior to multivariate
analysis.
4.1 Factor Analysis
24 items were used to measure perceptions toward advertising
on Facebook. Initial results of the factor analysis
on the 24 items came out with four factors. Since items with
loading of 0.45 and above and not cross loaded in
other factors were accepted, one items from privacy were
eliminated from the subsequent analyses. The
remaining 23 items were re-analyzed and the result is presented
in Table 2. The SPSS output is presented in
Appendix. From the table, the KMO measure sampling adequacy
values for the items was 0.666.
Table 2. Factor analysis on perceptions towards advertising on
Facebook

ITEMS 1 2 3 4
Perceived Interactivity
content. .878
Facebook. .810
hase a product advertised in Facebook. .754
advertised
in Facebook.
.745
other media
channels such as TV and radio as opposed to the ones advertised
in
Facebook.
.566 .353
about latest
fashion.
.555 .548 .330
Advertising Avoidance

.773
Facebook? -.369 .734
buying
or using.
.403 .713
link in
Facebook advertising.
.645
prevents me
from looking at ads on Facebook.
.531 .351
advertising. .585 .306
Credibility
products/services.
.575
consumer. .695

I am
looking for.
.853
.841
services. .827
that they
do not really need.
.830
Privacy
.609
159
interests. .490
Facebook advertising keeps me up to date about
products/services
available in the marketplaces.

.379 .557
every
time they logged in.
.376 .588
Eigenvalues 5.836 3.780 2.400 1.879
Percentages variance explained (%) 25.37 16.44 10.43 8.17
Total variance explained (%) 60.41
KMO .666
Bartlett’s Test of Sphericity 6444.109
3 items were used to measure perceptions toward Advertising on
Facebook. Initial results of the factor analysis
on the 3 items came out with one factor. Since items with
loading of 0.45 and above and not cross loaded in
other factors were accepted. The 3 items were re-analyzed and
the result is presented in Table 3.
Table 3. Factor analysis on attitudes towards advertising on
Facebook
ITEMS Factor 1

advertising on
Facebook?
.685
ward
advertising on
Facebook?
.667
advertising on
Facebook?
.712
Eigenvalues 5.345
Percentages variance explained (%) 100
Total variance explained (%)
KMO 0.707
Bartlett’s Test of Sphericity 1175.590
4.2 Reliability Analysis
Acceptable ranges of reliability of most instruments are ranged
from 0.7 to 0.9. The closer the alphas to 1, the
better the instruments are. Sekaran (2000) suggested that the
minimum acceptable reliability is at 0.60. The
Cronbach Alphas were computed for reliability testing. All the
items for each construct of the study possess

Cronbach α value above 0.60 except for one item in the
dimension of privacy which possessed below 0.60.
Based on Nunally (1967), the items for each construct in the
questionnaire are reliable and have internal
consistency. The results for the reliability tests for this study
are highly reliable as shown in Table 4.
160
Table 4. Results of reliability test
VARIABLES NUMBER OF ITEMS CRONBACH’S ALPHA
INDEPENDENT VARIABLES
Perceptions toward Advertising on Facebook 23 0.770
Perceived Interactivity 6 0.781
Advertising Avoidance 6 0.643
Credibility 6 0.630

Privacy 5 0.544
DEPENDENT VARIABLE
Attitude toward Advertising on Facebook 3 0.620
4.3 Hypothesis Results
By using regression analysis, the following results were
obtained (refer Table 5):
a) There is a significant positive relationship between perceived
interactivity and attitude towards the
b) There is significant positive relationship between
advertising avoidance and attitude towards the
c) There is significant positive relationship between advertising
avoidance and attitude towards the
d) There is positive relationship between credibility and attitude
Summary of the hypothesis results is presented in Table 6.
Table 5. Multiple regression analysis
Model
Unstandardized Coefficients

Standardized
Coefficients t Sig.
B Std. Error Beta
1
(Constant) 1.554 .161 9.635 .000
Total lnteractivity .134 .037 .201 3.623 .000
Total Privacy .338 .052 .406 6.523 .000
Total Avoidance .368 .047 .389 7.873 .000
Total Credibility .001 .045 .001 .020 .232
a. Dependent Variable: Total Attitude
Model Unstandardized
Coefficients
Standardized
Coefficients t Sig.
B Std. Error Beta
1 (Constant) 1.649 .164 10.031 .000
Total Perceptions .350 .051 .343 6.806 .000
a. Dependent Variable: TotalAttitude

161
Table 6. Summary of hypothesis results
Regression Result Remark
Perceived Interactivity 0.000 Supported
Advertising Avoidance 0.000 Supported
Credibility 0.232 Not Supported (Not significant)
Privacy 0.000 Supported
4.4 Discussions
Multiple regression results had partially supported the
hypothesis i.e. there is relationship between perceptions
toward advertising on Facebook and attitude towards the
advertisement on Facebook. As expected, the perceived
interactivity, privacy and advertising avoidance (three
dimensions of perceptions toward advertising on
Facebook) was found to be positively correlated with the

dimension of attitude towards the advertisement on
Facebook. Surprisingly, credibility (another dimension of
perceptions toward advertising on Facebook) was not a
significant predictor to attitude towards the advertisement on
Facebook. It is essential to understand how Internet
users perceive advertising on Facebook and what factors would
affect their attitudes towards Internet advertising.
Moreover, knowing what kind of content shall be put in the
advertisement or in what way of advertisements shall
be used would be helpful in enhancing marketing campaign
plan.
When consumers are skeptical of the advertising messages they
are receiving, or are skeptical of the media
source of the message, they will not be motivated to process the
information they are receiving. This may lead to
coping responses from consumers such as gathering information
from other sources or avoidance of the
advertising message altogether (Obermiller et al., 2005).
Unsuitable targeting techniques used by marketers in
delivering messages may also lead to lack of trust. Johnson and
Kaye (1998) stated that if consumers do not trust
or believe the media then they are less likely to pay attention to
it. Of late, there are a few reports that raised the
same detrimental issue. An independent research, Webtrends
(2011) reported that Facebook advertising
performance based on CTR was very low (0.051 percent),
although this may not affect the users but it definitely
has a major impact on Facebook as a credible platform of
advertising in the eyes of marketers. An online portal
Readwrite Social also raised the issue of Facebook’s credibility
on the ground of its email scanning practice,
albeit clarification by Facebook which pointing out an entirely
different issue of privacy (Copeland, 2012).
Therefore, it is of paramount importance to ensure that

resources should be more accurately allocated to the
media or channel and sources must be clearly verified after
knowing that users have concern about the credibility
issue pertaining to some advertising media especially
interactive ones like Facebook. This is because
informational interactivity plays major role in web and online
social network advertising since it is designed in a
way that allows for a user to search for and locate information
(Barnes, 2006).
5. Limitations and Future Research
As mentioned earlier, researchers who used limited-parent
population could only justify the dimensions
explaining the research framework without generalizing the
findings and drawing conclusions about the overall
public attitude towards advertising (Shavitt et al. 1998). In this
particular study, any conclusion drawn from this
limited-parent population sample (undergraduate students)
would be misleading because the sample basis does
not represent the total population despite the justifications as
mentioned above. The findings, however, represent
student perceptions from a sufficiently diverse range of
faculties and subject areas where Facebook has been
used. Thus, these exploratory findings represent a broad view of
the issues that arise. Future research may
consider using a more general and representative population of
Internet users (i.e. raising the sample size).
6. Conclusion and Implication
Hirschman and Thompson (1997) opined that issues in vast
areas of advertising must be tackled with a deeper
understanding of consumers’ relationships with advertising and
the media. This present study fully supports this
notion and, in addition, has discovered that any generic issues,

such as what were uncovered in this study, must
be seen from a specific media frame of reference (i.e.
Facebook). In this study, consumers’ perceptions such as
perceived interactivity, privacy and advertising avoidance have
great effects on the attitudes towards the
advertising in Facebook. From the findings of this research, the
marketers and advertising designers can also
understand and pay more attention on how the users of
Facebook perceive the advertisement when making
advertising decisions.
162
Besides providing literature for future scholarly research
avenues, it is also hoped that this will be a good starting
point for researchers to further examine attitudes towards other
specific popular and hybrid advertising
techniques like advergames and interactive digital television
before jumping on the bandwagon.
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Confidentiality and Electronic Medical Records for Behavioral
Health Records: The Experience of Pediatric Psychologists at
Four
Children’s Hospitals
Beverly H. Smolyansky and Lori J. Stark
Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio

Jennifer Shroff Pendley
A. I. duPont Hospital for Children/Nemours
Children’s Clinic, Wilmington, Delaware
Paul M. Robins
The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
Karin Price
Texas Children’s Hospital, Houston, Texas
With the advent of electronic medical records (EMR), pediatric
psychologists working
in medical centers must address how confidentiality of
behavioral health records will be
defined and integrated into the larger EMR. Pediatric
psychologists at four children’s
hospitals share their decision-making and outcomes as their
home institutions transi-
tioned to an EMR. All four formed committees of relevant
stakeholders and legal
advisors to define the legal and ethical issues and all four had
mechanisms to commu-
nicate provider concerns to and share committee opinions with
providers. Two of the
four required patients to give consent for behavioral health
records to be integrated into
the larger EMR, one integrated behavioral health records
completely without required
specific consent, and the fourth differentiated integration based
on the type of service
provided, with those focused primarily on physical health
concerns fully integrated and
those focused on behavioral health limited access to only

behavioral health providers.
The EMR at each institution allowed psychologists discretion to
keep individual notes
or portions of notes at a heightened level of confidentiality even
when integrated. At all
four institutions, medical colleagues valued having the
behavioral health records fully
integrated within the EMR, both the psychologists and their
medical colleagues
appreciate the improved communication with an integrated EMR
(whether by consent
or default), and the broader confidentiality protections of each
institution has ensured
that records are not accessed by those not involved in a
patient’s care. Most important,
families appear to appreciate the benefits of an integrated EMR.
Keywords: electronic medical record, behavioral health record,
confidentiality
Psychologists are obligated to maintain pri-
vacy and confidentiality of behavioral health
records based on the Ethical Principles of Psy-
chologists and Code of Conduct (American
Psychological Association, 2010). They are
therefore required to take reasonable steps to
Beverly H. Smolyansky, Division of Behavioral Med-
icine and Clinical Psychology, Department of Pediatrics,
Cincinnati Children’s Hospital Medical Center, Cincin-
nati, Ohio; Lori J. Stark, Division of Behavioral Medi-
cine and Clinical Psychology, Department of Pediatrics,
Cincinnati Children’s Hospital Medical Center and Uni-
versity of Cincinnati College of Medicine; Jennifer
Shroff Pendley, Division of Pediatric Behavioral Health,

Department of Pediatrics Nemours/Alfred I. duPont
Hospital for Children, Jefferson Medical College, Wil-
mington, Delaware; Paul M. Robins, Department of
Child and Adolescent Psychiatry and Behavioral Sci-
ences, Perelman School of Medicine at the University of
Pennsylvania, The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania; Karin Price, Section of Psy-
chology, Department of Pediatrics, Texas Children’s Hos-
pital, Baylor College of Medicine, Houston, Texas.
Correspondence concerning this article should be ad-
dressed to Lori J. Stark, PhD, Division of Behavioral
Medicine and Clinical Psychology, MLC 3015, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH
45229. E-mail: [email protected]
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Clinical Practice in Pediatric Psychology © 2013 American
Psychological Association
2013, Vol. 1, No. 1, 18 –27 2169-4826/13/$12.00 DOI:
10.1037/cpp0000009
18
mailto:[email protected]
http://dx.doi.org/10.1037/cpp0000009

secure patient data and share information only
with persons directly involved in the care of a
child. In the age of paper records, this was a
relatively simple task. Typically, records were
maintained by the individual psychologists in
their private offices, or, if practicing within a
larger hospital system, records were often kept
separate from the general medical record by
being kept in locked filing cabinets in the be-
havioral health division or department. Sharing
information only happened with direct written
consent from the patient or guardians. Privacy
was easy, but in a larger hospital system where
pediatric psychologists are involved in the care
of medical patients, this privacy came at the
cost of collaborative care and patient safety. For
example, emergency room physicians would
typically have no record that a child was in
therapy. Pediatric psychologists based in multi-
disciplinary clinics had to complete redundant
records, in the form of reports and letters to the
team, in order to share information. With the
advent of electronic medical records (EMRs),
many subspecialties moved to their use, stream-
lining documentation and billing. However, the
first electronic record systems were most often
implemented in isolated pockets of different
subspeciality practices. Thus, early electronic
record systems were unable to communicate
with one another and resulted in isolated islands
of data within hospitals.
In April of 2003, the Health Insurance Por-
tability and Accountability Act (1996; HIPAA)

went into effect. This law sets criteria for pro-
viders to protect medical information, increases
access of patients to these records, and man-
dates education of patients about their rights.
HIPAA did not replace state laws or the need
for consent, but it did put regulations in place
for behavioral health and other subspecialties to
consistently protect confidentiality of medical
records and patient data. HIPAA also attempted
to define “psychotherapy notes” as notes “doc-
umenting or analyzing the contents of conver-
sations during a private counseling session.”
The definition expressly excludes medication
prescriptions and monitoring, counseling ses-
sion start and stop times, the modalities and
frequencies of treatment furnished, results of
clinical tests, and any summary of the following
items: diagnosis, functional status, the treatment
plan, symptoms, prognosis, and progress to date
(HIPAA, 2003 sec. 164.501). Psychotherapy
notes, by design were notes that were never
meant to be read, would never be sent forward
for billing purposes, and would require a sepa-
rate release of information to access them; un-
der HIPAA, they were required to be kept sep-
arate from the medical record.
The rapid expansion of the use of electronic
medical records in hospitals followed a clear
timeline. In 2004, the federal government pol-
icy makers set a rather lofty, long-term goal that
electronic medical records should be in place
for all providers by 2014 (Hing & Hsiao, 2010).
By 2007, it was estimated that 34.8% of physi-
cians had instituted an electronic medical record

system (Hing & Hsiao, 2010). In 2009, the
federal government offered stimulus money to
assist hospitals in the development and adoption
of health information technology. Although
many hospitals, such as Cincinnati Children’s
Hospital Medical Center, had already decided to
make the move to an electronic medical record,
this money added an additional incentive to
accelerate this move. With this acceleration of
electronic medical records within hospital sys-
tems, pediatric psychologists have had to make
important decisions that balance confidentiality
and patient safety as well as state and federal
laws about confidentiality.
The purpose of this article is to highlight the
path taken by pediatric psychologists in four
children’s Hospitals (Cincinnati Children’s
Medical Center, A. I. duPont Hospital for Chil-
dren, Children’s Hospital of Philadelphia, and
Texas Children’s Hospital), to understand and
balance these issues as an EMR was introduced.
Of note, because all four hospitals chose Epic as
the EMR system, capabilities across all hospi-
tals were the same.
Cincinnati Children’s Hospital Medical
Center (CCHMC)
The Division of Behavioral Medicine and
Clinical Psychology (BMCP) is a freestanding
pediatric psychology service within CCHMC.
The majority of practicing pediatric psycholo-
gists are housed within the division, with the
major exception being psychologists housed
within the Division of Developmental and Be-

havioral Pediatrics (DDBP). Psychology pro-
vides care on an outpatient referral model, em-
bedded within medical teams (e.g., headache
clinic with neurology, pain clinic with anesthe-
19BEHAVIORAL HEALTH RECORDS AND EMR
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siology), an inpatient consultation liaison ser-
vice, and an outpatient child clinical service
through four CCHMC satellite locations. Epic
was introduced at CCHMC in March 2007 and
gradually implemented across three to five di-
visions a year. BMCP was rolled out in October
2009. Prior to Epic, BMCP had been using a
locally developed electronic system that al-
lowed psychologists within the division to ac-
cess each other’s patient records electronically
but that did not have electronic signature capa-
bilities. Therefore, all notes were printed and
stored in paper charts that were kept within the
division. Thus, we were comfortable with keep-
ing all behavioral health records separate from
the main medical record.

In anticipation of moving to an enterprise-
wide EMR in which records could be accessed
by other professionals within the institution,
CCHMC convened a mental health task force
about a year prior to going live to begin discus-
sions around sharing of behavioral health infor-
mation. This group consisted of a representative
from BMCP, psychiatry, DDBP, social work,
health information management (HIM), legal
counsel, the Chief Medical Information Officer,
and an Epic representative. Topics discussed
included (among other things) documentation
of abuse, use of sensitive notes designations,
releasing diagnoses on “After Visit Summary”
forms, public viewing of diagnoses and chief
complaints, and level of access needed for var-
ious staff positions. We also sought guidance
from the Ohio State Board of Psychology about
the ethics and legality of this integration. The
Ohio State Board advised us that, under Ohio
Administrative Code 4732–17– 01 (G)(1)(a),
when rendering psychological services as part
of a team or when interacting with other appro-
priate professionals concerning the welfare of a
client, a psychologist may share confidential
information about the client, provided that rea-
sonable steps are taken to ensure that all persons
receiving the information are informed about
the confidential nature of the information being
shared and agree to abide by the rules of con-
fidentiality. As a result of these discussions and
consultations, the division and the institution
reached a consensus that (a) all of the medical
record is to be considered confidential, and (b)
hiding things within medical records can be

dangerous for patient safety. CCHMC staff also
felt that, as an institution, they have taken steps
to ensure medical staff members are trained in
confidentiality and access of records, and had
steps in place to regularly monitor access of
records. Therefore, therapy progress notes cre-
ated by psychologists within BMCP would be
accessible to medical providers within
CCHMC, including all outpatient and inpatient
MDs, PhDs, nurses, and social workers. As a
division, it was also determined that our psy-
chologists do not keep “psychotherapy notes,”
as defined by HIPAA. Once it was established
that we were not using classically defined psy-
chotherapy notes, integrating behavioral health
records into the main medical record was
deemed appropriate. A final issue to be resolved
was how to handle psychological test protocols
because of copyright issues, the need to keep
test protocols from public access to preserve the
integrity of the tests, and the sensitive nature of
raw test data. We resolved this by determining
that psychological test protocols and raw test
data are not part of the official medical record.
To keep the test protocols separate from the
medical record, yet move to be totally elec-
tronic, we utilized Chartmaxx. Chartmaxx is a
separate electronic storage system from Epic
that can be linked to Epic for documents such as
school records, custody records, and so forth.
This is also the system used to electronically
store old paper medical records, as they are
gradually being eliminated by being scanned
into Chartmaxx. Chartmaxx has the capability
of linking or not linking a document to Epic

based on document type. HIM scans all testing
protocols into Chartmaxx in a file that is not
linked to Epic. Psychologists within the hospital
are the only professionals allowed to access this
confidential section of Chartmaxx. Thus, we
have been able to become completely electronic
and preserve the integrity of psychological test-
ing protocols.
In the context of these discussions and deter-
minations, it was also noted that there are times
when allowing access to psychology notes is not
clinically indicated. In the EMR there is an
option of marking a specific note as “sensitive”
in order to limit accessibility to particularly
sensitive information shared within the context
of the confidential relationship between psy-
chologist and patient or guardian. Marking a
psychology encounter as sensitive limits the
access to that particular note to only psycholo-
gists within the division (no other medical per-
20 SMOLYANSKY, STARK, PENDLEY, ROBINS, AND
PRICE
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sonnel, trainees, or support personnel). Other
hospital personnel would still be able to view
that an appointment had taken place, current
medication and diagnoses lists, and any therapy
notes not marked as sensitive. Psychologists
were trained to use the designation of “sensi-
tive” only for notes that contain information that
could place the trust inherent in the therapeutic
relationship in jeopardy, or when knowledge of
the content could adversely affect how others in
the institution treat the patient. Use of the sen-
sitive note was left to the clinical judgment of
the treating psychologist, with the caveat that
consideration should be given to the fact that the
designation of “sensitive” would also limit ac-
cess of potentially relevant clinical information
to other medical providers within the institution
and so should be used with care.
After “go live,” BMCP also took a few extra
steps to ensure appropriate access to records.
We asked for a monthly report from HIM on
who was accessing behavioral health records
through Chartmaxx (linked to Epic). The clini-
cal director reviews this report monthly and
HIM investigates any inappropriate access. In-
appropriate access has been very rare.
One challenge to an integrated EMR for be-
havioral health records was preconceived ideas
about the laws around confidentiality of indi-
vidual psychologists and psychiatrists. Change
is hard, and when that involved changes in how
we interpret ethical and legal guidelines for

confidentiality, it required listening to and ad-
dressing concerns of the clinicians. We had
many clinical discussions and updated psychol-
ogists throughout the Epic build for the divi-
sion. In the end, it came down to trust. At the
time of the “go live,” many psychologists were
not totally comfortable with the integration but
trusted that the institutional and divisional lead-
ership had considered the issues and were will-
ing to “see how it goes.”
Four years into Epic, the hesitations initially
voiced about an integrated EMR are gone, the
majority of the psychologists use the “sensitive
note” designation only on rare occasions, as it
was designed, and the psychologists, as well as
our medical colleagues, see the benefits of an
integrated EMR. Because psychology and psy-
chiatry are separate divisions at CCHMC, an
integrated EMR has increased communication
and care coordination for patients we share, as
psychologists now have access to notes includ-
ing inpatient psychiatry and medication man-
agement. For the psychologists imbedded in
medical subspecialty clinics, using one EMR
improved communication within those clinics
and satisfaction with the coordination of care of
complex medical patients by our medical col-
leagues.
Patient feedback has been neutral to positive.
Many parents are familiar with EMR at other
physician offices and typically had no concerns
with behavioral records in Epic. Many parents
gave spontaneous positive feedback about the

advantages of the psychologist having knowl-
edge of visits to other doctors. Many parents
shared how grateful they were to not have to
repeat medication lists, and so forth. One issue
we had to address was how to manage the notes
if the patient was the child of an employee. In
this case, we decided to give employees the
option of having notes marked as sensitive.
Some parents are thankful for this option; most
have chosen not to have notes marked this way
so that their child’s care can be coordinated
across other clinics and physicians who also
treat their child.
Nemours Children’s Health System/A. I.
duPont Hospital for Children (DHC)
The Division of Behavioral Health is part of
the Department of Pediatrics within DHC. The
majority of psychologists are housed within be-
havioral health, with the exceptions of neuro-
psychologists housed in rehabilitation and psy-
chologists who have shared appointments in
other medical specialties, for example, cardiol-
ogy. In addition, the Nemours Children’s
Health System also includes psychologists lo-
cated in children’s clinics in Florida. Similar to
CCHMC, Nemours psychologists provide care
on an outpatient referral model, an inpatient
consultation liaison service, and in outpatient
services embedded within Nemours primary
care satellite clinics.
Nemours Children’s Health System began
converting to EMR for outpatient services on a
division by division “go live” process in 2000.

At this time, a number of issues were consid-
ered. Similar to CCHMC, the issues of confi-
dentiality and privacy were of utmost impor-
tance, and a well-qualified team of professionals
participated in ongoing discussions, evalua-
tions, and decision making to ensure this pro-
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cess was both effective and well informed. This
group included psychologists and psychiatrists
from Delaware and Florida, legal counsel, the
Medical Director of Health Informatics, other
Epic representatives, and HIM representatives
who handle releases of information to external
agencies. In order to make the transition to
EMR as smooth as possible for providers and
families, several topics were discussed. These
included the legal issues relating to HIPPA in
both Florida and Delaware; the definition of
therapy and progress notes; families’ rights to
determine who has access to their records; the
assurance that families are clearly informed

about the issues of privacy and confidentiality
related to their medical records; the effective
use of “sensitive notes” designations; the appro-
priateness of various providers viewing diagno-
ses, problem lists, and medications; and the
ability to monitor unauthorized access of re-
cords.
Initially, both physicians and behavioral
health staff had access to behavioral health
notes. Similar to CCHMC, we believed that
physicians were trained in confidentiality and
access of records, and additional parental con-
sent for these providers to access behavioral
health notes was not required. However, be-
cause Nemours provides services in both Dela-
ware and Florida, the laws of both states relat-
ing to HIPPA regulations were examined, and
the more conservative law (Florida) took prece-
dence. Subsequently, the decision was made for
all behavioral health notes to be accessible to
behavioral health staff only. Moreover, the ad-
ditional level of protection for outpatient notes
only applied to services scheduled within the
Division of Behavioral Health. Although this
applied to the vast majority of outpatient visits,
behavioral health notes were not protected when
patients were seen by psychologists who sched-
uled through other services (e.g., General Pedi-
atrics), as, similar to CCHMC, these notes were
not considered “psychotherapy notes.” Simi-
larly, in 2009, when our inpatient records tran-
sitioned to Epic, inpatient psychological consul-
tation notes were not protected because these
services were considered to occur outside the
Division of Behavioral Health. Due to psychol-

ogists’ role as consultants to inpatient services,
legal counsel felt that expectations of privacy
and confidentiality differed from those of the
outpatient clinic within the Division of Behav-
ioral Health.
Initial patient feedback was quite varied;
some patients expressed appreciation for pri-
vacy, whereas others expressed frustration that
other medical providers did not have access to
their records. Physicians, particularly our pri-
mary care physician colleagues, initially made
weekly complaints regarding their limited ac-
cess to behavioral health records, as they felt
this impeded their ability to provide optimal
patient care. Subsequently, we developed a par-
ent consent form that allowed parents to choose
whether the behavioral health portion of their
electronic medical record was accessible to
other Nemours providers. Although initially all
behavioral health notes were deemed confiden-
tial until the family gave consent, the default
eventually changed to all notes being accessible
unless a family specifically denied consent. This
system seemed to resolve both patient and phy-
sician frustration.
However, even if notes are accessible to other
medical providers, psychologists do have some
discretion in sharing information. Specifically,
psychologists can utilize a “sensitive note”
function that is available through the Epic sys-
tem. If a patient has allowed access to notes but
reveals highly sensitive information during a
session, the psychologist can mark the note for

that session only as “sensitive.” Alternatively, if
the session contained both sensitive information
and information pertinent to patient’s medical
care with other Nemours providers, the psychol-
ogist can document sensitive information in a
separate progress note. For example, if a psy-
chologist and patient with diabetes are working
on adherence concerns, information regarding
goals and progress can be noted in the progress
note and viewed by the endocrinologist, if the
patient has granted consent for access. How-
ever, if the patient or parents discussed a highly
sensitive issue, a second progress note can be
written for the same encounter and marked
“sensitive.” Sensitive notes can be viewed only
by that psychologist and others whom the psy-
chologist has designated a proxy. All behavioral
health clinicians are proxies for each other in
order to allow coverage when needed. Like
CCHMC, psychological testing protocols are
not considered part of the medical record. How-
ever, unlike CCHMC, we keep these protocols
in paper charts.
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We have experienced several benefits related
to going to an EMR. It has increased collabor-
ative care across behavioral health and medical
providers. With parental consent, other medical
providers involved in the child’s care have ac-
cess to all records, helping to ensure integrative
and collaborative care. Families do not have to
repeat their history as often, and other providers
are aware of mental health issues that could
affect medical treatment. The EMR system al-
lows for much flexibility in how notes are
viewed. Importantly, it is a family-centered ap-
proach, such that families have the decision-
making power, along with their therapist, re-
garding the accessibility of their notes by other
medical staff. Most families have allowed ac-
cess to their notes. Furthermore, the flexibility
of the “sensitive note” function allows for some
discretion on the part of the provider.
There were a few challenges to implementa-
tion and to management in the face of continued
growth of our medical center. Once we imple-
mented a process whereby families could con-
sent to the sharing of their behavioral health
records as an integrated part of the EMR, the
vast majority of medical staff members ap-
peared satisfied with this consenting process
and complaints have greatly decreased. How-
ever, there remains a small minority who feel
that all behavioral health records should be ac-
cessible regardless of the family’s wishes. We

continue to have discussions about this with
both physicians and families. As behavioral
health notes become part of electronic medical
records, it is important that clinicians write in a
way appropriate for a medical chart. We have
found this writing style may be a very different
style than many psychologists have used in the
past and should be addressed within psychology
graduate training programs to prepare graduate
students for this new reality.
Because of the confidential designation for
behavioral health visits (i.e., for families who
have denied access to other providers), the Epic
team encountered challenges regarding sched-
uling of outpatient appointments. A different
scheduling code must be used for families that
decline to share their behavioral health visits
with other medical providers than visits for fam-
ilies who have granted access. Therefore, sched-
ulers must know in advance how a visit should
be scheduled within Epic. In addition, processes
to inform families, gain signed consent, and
document these procedures had to be designed
and implemented. Additionally, behavioral
health clinicians must approve any release of
information request that comes through HIM.
One potential upcoming challenge concerns
access for school nurses. Nemours has launched
a new program that allows school nurses to have
access to Epic, contingent on families’ consent.
However, although families may want school
nurses to have access to diabetes regimens or
asthma medications, they may be uncomfort-

able with school nurses having access to behav-
ioral health therapy notes. At this initial stage of
development, behavioral health notes, but not di-
agnoses, cannot be viewed by the school nurses.
We are certain this will continue to be a topic of
discussion.
The Children’s Hospital of Philadelphia
(CHOP)
The Department of Child and Adolescent
Psychiatry and Behavioral Sciences (DCAPBS)
is one of six departments within CHOP. It is the
discipline-specific home for all licensed psy-
chologists, child and adolescent psychiatrists,
licensed clinical social workers, and licensed
behavioral health practitioners within CHOP.
With over 90 licensed mental health providers
across two states, psychologists provide ser-
vices within medical inpatient, medical outpa-
tient, mental health outpatient, integrated pedi-
atric primary care, and satellite subspecialty
care settings. Departmental policies and proce-
dures, including use of the electronic medical
record for behavioral health documentation, ap-
ply to all CHOP licensed behavioral health pro-
viders, regardless of their physical location or
department/division affiliation. That is, the Epic
security profile is determined by role, not phys-
ical location within the hospital system.
Similar to CCHMC, the EMR rollout at
CHOP was a multiyear process. Divisions “go
live” as their build is complete, on a rolling
basis. DCAPBS, the home for all licensed psy-
chologists, psychiatrists, and clinical social

workers, went live in October 2012. DCAPBS
has many psychologists embedded in other de-
partments/divisions. As a result, psychologists
in those departments/divisions (e.g., feeding
psychologists) went live with their respective
divisions, and issues relevant to protecting men-
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t
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br
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dl
y.
tal health privacy in medical records was pre-
viously addressed for these psychologists.
As the DCAPBS approached the Epic build,
the Epic team benchmarked with other hospitals
regionally and nationally to learn about imple-
mentation of mental health privacy. What we
learned was significant heterogeneity of prac-
tice, continuous changes in practice, and hybrid
practices. DCAPBS formed a committee of ma-
jor stakeholders within the department to work
closely with the Epic team and build the plat-
form for the department. This committee and
subcommittees worked on a regular and ongo-

ing basis through the build and implementation
process. The recommendations from this com-
mittee flowed through the chair of DCAPBS.
The department chair also met with other de-
partment heads to help learn what they needed
to know with respect to behavioral health re-
cords. For example, the emergency department
had specific needs with respect to the behavioral
health records of patients seen acutely.
Emerging from this early phase process, it
was determined that the following information
would be accessible to all clinical users within
the EMR system on a “need to know” basis:
diagnosis, psychotropic medications, safety
screening and safety plan information, and ap-
pointments with mental health providers. It was
determined that certain diagnosis data, not rel-
evant or of limited value to the general provider
community, would not be listed in the diagnosis
section of the record. A critical decision was the
handling of behavioral health progress note
data. If the principal reason for the visit was a
behavioral health concern, then the progress
note documenting psychotherapy is not view-
able to providers outside of DCAPBS as the
default setting. The note is viewable to all li-
censed behavioral health providers, including
psychiatrists, psychologists, clinical social
workers, psychiatric nurse practitioners, and li-
censed professional counselors. On the other
hand, if the principal reason for the visit was a
primary physical health concern, then the prog-
ress note documenting psychotherapy is view-
able to all providers on a “need to know” basis
as the default setting. For example, our pediatric

psychologists typically work within interdisci-
plinary teams, and their notes are viewable. In
either case, the writer/provider can forward the
note to other providers using the “in-basket”
Epic function. In addition, a provider can
change the default setting (e.g., “mental health
sensitive” to nonsensitive) on a case-by-case
basis. This two-tiered Epic confidentiality ap-
proach was deemed necessary due to essential
differences between the outpatient mental
health and the outpatient and inpatient behav-
ioral health practices within our department. In
addition, it safeguarded the very rare, but real-
istic, concerns when children of very high pro-
file parents are treated within the department. It
was essential in the build process that the pedi-
atric psychology practice strongly advocate for
the ability of all providers to view progress
notes on a “need to know” basis. As our practice
differs in many essential ways from our outpa-
tient mental health colleagues, the need for
greater transparency and across discipline inte-
gration was necessary and took a number of
planning sessions to accomplish. Nonetheless,
all providers use a standard set of templated
progress notes. These templates were developed
and approved by the Department Quality Im-
provement and Epic build committees, and are
compliant with current Joint Commission on the
Accreditation of Healthcare Organizations and
billing requirements.
All records completed by any licensed behav-
ioral health clinician are identified in Epic as a
mental health record for purposes of HIM re-

lease to third parties. Every behavioral health
progress note is electronically bordered by an
exclusive behavioral health banner (color
coded), with embedded language specific to the
release of the note to any third party. In addi-
tion, all requests for release of any part of a
mental health record goes through HIM, and the
attending mental health provider needs to au-
thorize the release. These processes/procedures
protect the release of protected behavioral
health information.
Although it is too early to obtain systematic
feedback from patients and other providers, an-
ecdotal data suggests that having an integrated
electronic medical record has clearly facilitated
the sharing of information between behavioral
health providers. As we practice across multiple
locations, obtaining and sharing patient charts
from other locations has been extremely chal-
lenging up to this note. The integrated elec-
tronic record allows improved treatment plan-
ning across previous “siloed” behavioral health
practices.
PRICE
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y.
Moving forward, the hospital is forming a
Specially Protected Information (SPI) commit-
tee, consisting of representatives of HIM, Epic,
legal, risk management, patient safety and qual-
ity, and the hospital Chief Medical Officer. This
committee will review policies and processes
for all specially protected health information,
such as that generated by adolescent pediatri-
cians, and so forth, and better determine the
sharing of “sensitive” information within the
EMR.
Texas Children’s Hospital (TCH)
The large majority of practicing pediatric
psychologists at TCH practice within the Psy-
chology Service, which is academically affili-
ated with the Section of Psychology within the
Department of Pediatrics at Baylor College of
Medicine. There are also small pockets of psy-
chologists housed within other medical subspe-
cialty services (e.g., adolescent medicine, psy-
chiatry, developmental pediatrics). Assessment
and intervention services are provided through
outpatient behavioral health clinics, inpatient
and outpatient care as members of collaborative
medical teams (e.g., oncology, endocrine, bari-
atric surgery), and through large pediatric prac-
tices that are a part of the TCH Integrated De-
livery System.

TCH recently had the opportunity to rethink
how behavioral health records would be man-
aged within our EMR as we moved from a more
outdated EMR (Logician) to a more updated
one (Epic). In our setting, Epic was conceived
as a shared medical record for TCH main
campus, associated pediatrician offices in the
community, centralized multispecialty health
centers, a community-based auxiliary hospital
setting, and a women’s health pavilion. Un-
like the other settings referenced above, Epic
at TCH went “live” in a series of large waves
that were based on location of care (e.g., emer-
gency department, inpatient, pediatric associ-
ates, ambulatory), over an approximately two-
year period. In making decisions about how to
manage confidentiality issues, we consulted
with Epic experts, HIM leaders, the Texas State
Board of Examiners of Psychologists, and a
TCH compliance/security officer. In addition,
we had the benefit of working with colleagues
who had used Epic in other settings (CCHMC,
DuPont) where behavioral health documents
were treated in different ways. Finally, we con-
vened a task force with psychology representa-
tion from all divisions (psychology, psychiatry,
developmental pediatrics, adolescent medicine)
to design templates, bring information to the
wider faculty, and vote on decisions to be
brought to the institutional Epic development
team.
As part of the larger institution, a decision
was made to use a “break the glass” approach
for employee records and records of employee’s

family members. Partially because of not want-
ing to overuse this system, it was decided to not
use this as a possible mechanism for protecting
confidential documents. As such, we were left
to ponder the use of “sensitive notes and “sen-
sitive encounters.” Briefly, a note can be
marked as “sensitive” and still viewed by any
person with provider-level security access to
Epic, but the provider is warned that the note
they are accessing is sensitive. A “sensitive
encounter” can only be viewed by individuals
listed on a proxy list. We decided that both
mechanisms would be used, though in limited
ways. In making this decision, a large number
of issues were discussed. First and foremost
were conceptual issues around what informa-
tion in a shared EMR should remain confiden-
tial. We then discussed limitations of the Epic
system from a programming perspective and
made compromises as needed. For example,
diagnoses, problems lists, and medications are
never considered protected information.
Throughout this process, we discussed how
session notes, reports, phone calls, and letters to
families should be treated. We decided as a
default, every note created by a psychologist
in our setting would be marked as sensitive. In
part, this creates a barrier for release of medical
records without the attending psychologist’s
permission (i.e., HIM professionals receive a
flag when opening a sensitive note, which cre-
ates pause before an automatic release hap-
pens). Psychologists in this setting also have the
option of making an encounter sensitive. Our
proxy list includes all psychologists in the or-

ganization (regardless of home department) and
psychiatrists in the Department of Psychiatry.
This allows for better coordination of care
among these providers. Administrative, billing,
Epic, and HIM staff are also added to the list on
an as-needed basis. The main issue we have
discovered with the use of a proxy list is one of
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maintenance as adding and removing trainees
every cycle has become somewhat cumber-
some.
Of note, providers have the option of having
their encounters made sensitive, and factors im-
pacting the decision to use this option have
evolved over time. Many providers initially
used the sensitive encounter for all of their
encounters. However, similar to DHC, we be-
gan to receive feedback from referral sources—
particularly those located in our related pedia-
trician offices—that they were unable to get the

information they needed about their patients in
order to make informed treatment decisions.
When the psychologist sent an “in basket” mes-
sage to the child’s pediatrician, the messages
were frequently buried. When we faxed our
reports to the pediatrician’s office, they often
were scanned into the EMR and therefore no
longer protected as confidential.
To solve this dilemma, we met with repre-
sentatives of the pediatrics practices, who
shared that they would like to see reports from
diagnostic interviews and also receive informa-
tion regarding treatment attendance and prog-
ress. These representatives expressed frustration
that when an encounter was made sensitive, any
record of that appointment having occurred dis-
appeared (i.e., the appointment disappears from
the schedule), whereas no-show and canceled
appointments remained viewable. The effects of
sensitive notes left referring pediatricians with-
out any sense of whether a family was following
through with treatment recommendations. The
agreed-upon solution was that diagnostic inter-
view encounters would not be made sensitive,
and that although therapy notes would remain
sensitive, providers would write brief treatment
summaries at the end of treatment that would
not be sensitive and therefore would be acces-
sible to other providers. This involved a change
in language on our consent form, as well as a
change in procedure for verbally reviewing the
release of information with parents and guard-
ians. Our current practice is to keep all diagnos-
tic and testing reports accessible unless the par-
ents or guardians specifically object when this is

reviewed during the initial appointment. Parents
seem to be very satisfied with this approach, and
the number of families requesting that their
child’s records remain confidential from other
medical professionals involved in their child’s
care has been close to none.
Similar to the other hospitals, our biggest
barrier to implementing these changes was our
own providers’ initial discomfort with having
notes more accessible in the EMR. As indicated,
we used consensus building, education, and
changes to our consent process to increase in-
dividual providers’ comfort level with the deci-
sions that were made. Finally, giving families
and psychologists some autonomy in deciding
what portions of the behavioral health record
should be kept confidential from other providers
in the medical setting has been helpful, and no
issues related to this have arisen thus far.
Discussion
EMR is the environment in which pediatric
psychologists in medical settings will be pro-
viding and documenting care. It is our hope that
by sharing the process and decision making of
four institutions, our experiences will assist
other pediatric psychologist as their settings “go
live” with an EMR or continue to manage the
ongoing concerns and issues that arise around
confidentiality of behavioral health records.
It is clear from the four descriptions that each
institution approached the issues of confidenti-
ality quite comprehensively. Each institution

convened teams that consisted of behavioral
health providers and legal experts. They also
reviewed state and federal laws surrounding
confidentiality. As is the case for all health care
providers, pediatric psychologists must follow
the most conservative laws around confidenti-
ality. The impact of this was most clearly seen
in how Nemours had to modify the integration
of the behavioral health record because of the
more strict law in Florida compared with Del-
aware. However, this difference in state laws is
also reflected in the differences between
CCHMC and the other institutions. Ohio law
allowed CCHMC to set the default of having
behavioral health records being fully integrated
into the EMR.
No matter how the legal aspects of confiden-
tiality were resolved, it is also clear that the
divisions or departments that housed pediatric
psychologists (and other behavioral health pro-
viders) recognized the benefit of sharing the
behavioral health record to integrated patient
care and to patient safety. Despite this recogni-
tion, much work was done across the institu-
tions to increase the comfort level of the pedi-
PRICE
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ss
oc
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on
or
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it
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he
rs
.
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cl
e
is
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te
nd
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ly
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of
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atric psychologists with having therapy notes
part of an integrated EMR. Even at CCHMC,
where integration was the default, psychologists
could have overwritten this by marking every
note as sensitive within Epic. For the other
institutions, families would likely not consent if
their psychologist did not present the option in
a favorable light. To overcome reservations of
the psychologists, each institution took care to
listen to the concerns, to respond to them, and to
allow for clinical discretion of when some prog-
ress notes should not be shared. It is also im-
portant to note that, under HIPAA, there are
serious repercussions for viewing a medical re-
cord when the health professional is not in-
volved in the care of the patient and tracking of
unauthorized viewing is now possible with an
EMR. In all four institutions, the ongoing expe-
rience of the psychologists with an integrated
EMR has done the most to increase comfort
with the system.
Perhaps the important learning from the ex-
perience of the four institutions is the over-
whelmingly positive response of our medical
colleagues to the integration of the behavioral
health record into the EMR, whether it was
done by a consenting or default. Most of us
went into pediatric psychology for the opportu-

nity to work with our medical colleagues to
improve the health of children. Finding ways to
integrate our work into the EMR moves us
closer to that goal by allowing our colleagues to
learn, understand, and know specifically what
we are doing and how the patient is responding
to our treatments. EMR integration decreases
the administrative burden of sharing this infor-
mation. It is also notable that, across all four
institutions, patients and their families see the
advantages of integrating behavioral health re-
cords within the EMR, and even in the institu-
tions requiring a consenting process, most fam-
ilies opt in. The psychologists also appreciate
and find that being able to access the medical
record for the patients and families referred
results in better and more integrated care on our
side as well.
In closing, these learnings not only are
important for pediatric psychologists already
in the field but also have implications for how
we train current and future graduate students.
It will be important that graduate students
learn about the definitions of confidentiality
beyond the American Psychological Associa-
tion’s ethical guidelines, and understand the
role of state and federal laws and how these
differ and how to determine what takes prec-
edent. As mentioned by Nemours, progress
notes that will be integrated into an EMR may
require a different style than when notes were
kept within a behavioral health area only. As
noted, CCHMC determined that none of the
notes met the definition of psychotherapy

notes and thus were not automatically subject
to the stricter HIPAA protection clause. This
is likely because, far in advance of an EMR,
it was acknowledged that we should write
every note from the perspective of the parent
requesting and reading it. Therefore, our
notes were already family friendly in docu-
menting the treatment and how the child was
responding, and did not include interpretation
of behavior or actions. The purpose of an
EMR is to allow fully integrated care to im-
prove outcomes and protect patient safety.
Clearly, the learnings from the four institu-
tions support the benefits of working within
the laws of confidentiality to share our behav-
ioral health records.
References
American Psychological Association. (2010). Ethical
principles of psychologists and code of conduct.
Retrieved from http://www.apa.org/ethics/code/
index.aspx
Health Insurance Portability and Accountability Act
of 1996, 42 U.S.C. § 1320d-9 (2010).
Hing, E., & Hsiao, C. J. (2010). Electronic medical
record use by office-based physicians and their
practices: United States, 2007. National Health
Statistics Reports, 23, 1–11.
Ohio Administrative Code, chap. 4732–17, Rules of
Professional Conduct, 4732–17– 01. General rules
of professional conduct pursuant to section
4732.17 of the Revised Code. Retrieved from

http://codes.ohio.gov/oac/4732–17
Summary of the HIPAA Privacy Rule. (2003). Re-
trieved from http://www.hhs.gov/ocr/privacy/
hipaa/understanding/summary/privacysummary
.pdf
Received December 29, 2012
Accepted January 2, 2013 �
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by

th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of

it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so

le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d

is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
www.apa.org/ethics/code/index.aspx
www.apa.org/ethics/code/index.aspx
codes.ohio.gov/oac/4732-17
www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacy
summary.pdf
summary.pdf
summary.pdfConfidentiality and Electronic Medical Records for
Behavioral Health Records: The Experience of ...Cincinnati
Children`s Hospital Medical Center (CCHMC)Nemours
Children`s Health System/A. I. duPont Hospital for Children
(DHC)The Children`s Hospital of Philadelphia (CHOP)Texas

Children`s Hospital (TCH)DiscussionReferences
C:/Postscript/07_Pier_MHFM5_1_D1.3d – 30/4/8 – 9:33
[This page: 29]
Article
A controlled trial of internet-based
cognitive-behavioural therapy for panic
disorder with face-to-face support from a
general practitioner or email support from
a psychologist
Ciaran Pier BA(HonsPsych) PhD
Lecturer in Psychology, School of Psychology, Deakin
University, Victoria, Australia
David W Austin BBus GradDipPsychStudies GradDipAppSci
PhD
Senior Lecturer
Britt Klein BA(Hons) DPsych(Clinical)
Senior Lecturer
Joanna Mitchell BA MA GradCert(Psych) BBSc(HonsPsych)
MPsych(Clin)
Research Fellow
Faculty of Life and Social Sciences, SwinPsyCHE e-Therapy
Unit, Victoria, Australia
Peter Schattner MD MMed FRACGP
Associate Professor

Lisa Ciechomski BA GradDipEdPsych MPsych PhD, MAPS
Research Fellow
Kathryn J Gilson Bsc(Hons) DPsych(Clinical)
Research Fellow
Department of General Practice, School of Primary Health Care,
Faculty of Medicine, Nursing and Health
Sciences, Monash University, Victoria, Australia
David Pierce MBBS MGPPsych MMed FRACGP FACPsychMed
DipRACOG
Senior Lecturer, School of Rural Health, University of
Melbourne, Ballarat, Australia
Kerrie Shandley Bsc GradDipPsych MPsych (Health)
Research Assistant, Faculty of Life and Social Sciences,
SwinPsyCHE e-Therapy Unit, Victoria, Australia
Victoria Wade BM BS BSc GradDip AppPysch MPysch
FRCAGP
Chief Executive Officer, SA Divisions of General Practice Inc,
Wayville SA, Australia
Mental Health in Family Medicine 2008;5:29–39 # 2008
Radcliffe Publishing
[This page: 30]
C Pier, DW Austin, B Klein et al30

Introduction
Panic disorder (PD) is one of the most common
anxiety disorders in the Australian community,
but is consistently undertreated. In any 12-month
period, approximately 2% of Australians are afflicted
by PD; however, the majority (61%) of people with
PD with/without agoraphobia do not seek or receive
professional assistance.1
Clinical trials have demonstrated that cognitive-
behavioural therapy (CBT) is the most effective
treatment for PD, and recent findings suggest that
CBT confers longer-term benefits than selective sero-
tonin reuptake inhibitor (SSRI) alone or CBT and
SSRI in combination.2–4 Multi-element CBT treat-
ment protocols for PD result in panic-free status for
75–95% of patients, with improvements maintained
for at least two years.5–7 Importantly, CBT is also
uncompromised by co-morbid depression,8 or the

transfer from research to clinical treatment set-
tings.9
Despite the demonstrated efficacy of CBT, a lack
of access to specialist mental health services and
their high cost impede provision of this best-prac-
tice treatment. Access to mental health services is
also limited in the UK and Ireland.9,10 People residing in
rural and remote areas are particularly disadvantaged
by the shortage of mental health services.11 In
Australia the accessibility of mental health services
is likely to improve with the federal government’s
recent changes to the healthcare system which en-
able general practitioners (GPs) to refer patients
to eligible psychologists for a limited number of
reduced-fee consultations. Nevertheless, many people
will be unable to afford the reduced fee or ongoing
consultations, and inaccessibility due to geographic
isolation will remain a significant problem.

Partly as a consequence of the historical difficulty
in accessing mental healthcare, most people seeking
assistance for a mental illness first consult their GP.13
Indeed, between one-quarter and one-half of gen-
eral practice patients have a mental health prob-
lem.14,15 Seeking assistance from a GP has several
advantages, including the provision of rapid and
affordable access to comprehensive healthcare with-
out the stigma often associated with attending
specialist psychological or psychiatric services. Com-
pared to other healthcare professionals, GPs are
accessible, large in number and can be seen at little
or no direct cost to the consumer.16
Nevertheless, there are considerable shortfalls in
the provision of mental healthcare within this set-
ting, with skill limitations and time constraints
being the prominent difficulties.15,17 Furthermore,
many patients who present with sufficient disturbance

ABSTRACT
Background Panic disorder (PD) is one of the
most common anxiety disorders seen in general
practice, but provision of evidence-based cogni-
tive-behavioural treatment (CBT) is rare. Many
Australian GPs are now trained to deliver focused
psychological strategies, but in practice this is
time consuming and costly.
Objective To evaluate the efficacy of an internet-
based CBT intervention (Panic Online) for the
treatment of PD supported by general practitioner
(GP)-delivered therapeutic assistance.
Design Panic Online supported by GP-delivered
face-to-face therapy was compared to Panic Online
supported by psychologist-delivered email therapy.
Methods Sixty-five people with a primary diag-
nosis of PD (78% of whom also had agoraphobia)
completed 12 weeks of therapy using Panic Online

and therapeutic assistance with his/her GP (n = 34)
or a clinical psychologist (n = 31). The mean
duration of PD for participants allocated to these
groups was 59 months and 58 months, respect-
ively. Participants completed a clinical diagnos-
tic interview delivered by a psychologist via
telephone and questionnaires to assess panic-re-
lated symptoms, before and after treatment.
Results The total attrition rate was 20%, with no
group differences in attrition frequency. Both treat-
ments led to significant improvements in panic
attack frequency, depression, anxiety, stress, anxiety
sensitivity and quality of life. There were no stat-
istically significant differences in the two treatments
on any of these measures, or in the frequency of
participants with clinically significant PD at post
assessment.
Conclusions When provided with accessible

online treatment protocols, GPs trained to deliver
focused psychological strategies can achieve patient
outcomes comparable to efficacious treatments
delivered by clinical psychologists. The findings
of this research provide a model for how GPs may
be assisted to provide evidence-based mental
healthcare successfully.
Keywords: agoraphobia, internet therapy, men-
tal healthcare in general practice, panic disorder
[This page: 31]
Internet CBT for panic disorder in general practice 31
to warrant further specialised mental health treat-
ment are also not referred appropriately.18,19
To address these shortfalls, the Australian govern-
ment implemented the Better Outcomes in Mental
Health Care Initiative (BOiMHC), which provides

educational and financial structures for GPs to use
time-limited focused psychological strategies (FPS)
that incorporate key elements of CBT. Nevertheless,
even GPs who are trained in FPS often do not have
the time, or the access to resources, to deliver com-
prehensive evidence-based CBT programmes to
patients with mental illnesses. There is a need for
ongoing training and support, beyond training in
FPS.20
The use of internet-delivered CBT programmes in
general practice may facilitate the delivery of best-
practice care for GPs with FPS training. Internet-
based programmes can provide accessible CBT with-
out the need for intensive therapist involvement,
and may therefore increase access to affordable
treatments.
Most internet therapy programmes for PD have
involved limited therapist assistance via email, with

early reports indicating that internet-based CBT
for PD was as effective as applied relaxation and
waiting-list control conditions.21 Building on the
findings of Richards and colleagues’ previous internet-
based CBT information programmes,22,23 Klein et al
evaluated a six-module, structured CBT programme
for PD, with or without agoraphobia, called Panic
Online (PO).24 Participants used the programme
and interacted with a psychologist via email. Klein
et al compared their PO treatment with two con-
ditions, either a self-help CBT manual plus weekly
telephone-based CBT, or provision of panic-related
information plus limited telephone contact. Both
CBT-based treatments were more effective than the
information condition for improving panic-related
symptomatology and cognitions and negative af-
fect. However, PO was more effective than the CBT
manual for improving agoraphobia and frequency

of GP visits. At three-month follow-up, those who
received PO also had significantly improved physi-
cal health ratings.
Subsequently, Richards and colleagues compared
the same PO programme with a larger intervention
comprising all the features of PO plus additional
stress-management modules.25 At post-treatment,
both PO programmes were more effective than an
information-only condition. Panic Online plus
stress management was more effective than PO
alone for improving PD severity and general
anxiety, although at three-month follow-up these
differences were no longer apparent.25 In combi-
nation, these studies attest to the efficacy of PO for
producing clinically significant improvements in
PD.
Despite the recent call for internet-based mental
health treatment and practitioner support within

primary care,26 most published research on primary
care internet interventions has focused on physical
health-related behaviours.27,28 There is some evi-
dence that self-help treatments in the form of writ-
ten or audio-behavioural or cognitive-behavioural
materials, delivered in primary care, confer clinical
benefits.29,30 However, the methodological short-
comings of several such studies have been noted,29
as have contrary results.31 Furthermore, a literature
search failed to reveal published research on the
effectiveness of internet-based CBT programmes
delivered by GPs, for the treatment of panic dis-
order.
Responding to this evidence gap in the literature,
this study investigated the effectiveness of PO with
face-to-face assistance provided by a GP (PO-GP),
compared to PO with email assistance from a psy-
chologist (PO-P), for treating PD, with or without

agoraphobia. This study is one of the first to directly
compare two different ways of delivering internet-
based CBT for PD, and provides new information
about the effectiveness of an internet-based mental
health intervention applied to a primary care set-
ting. If PO-GP is found to be as effective as PO-P, this
programme will serve as a model for the implemen-
tation of evidence-based CBT programmes in primary
care. It was predicted that the PO-GP would be as
effective as PO-P for treating panic disorder, with or
without agoraphobia.
Method
Recruitment
The study was advertised to the general public via
Australian mental health websites and local and
national media. Interested individuals were directed
to the panic online website to self-register for the
study.

The study was also promoted directly to GPs via
several BOiMHC-accredited mental health training
programmes in Victoria and South Australia. This
served the dual purpose of recruiting GPs to partici-
pate as treating GPs in the PO-GP group, and/or to
encourage referral of patients to the study. GPs who
indicated an interest in participating in the pro-
gramme were contacted by telephone and registered
for the study. All GPs who registered were given
access to the website and sent written materials about
the study. Considerable time was also spent corre-
sponding with registered GPs about their involvement
in the research. A research officer (also a registered
[This page: 32]
C Pier, DW Austin, B Klein et al32
psychologist) either met with each GP or, if the GP

preferred, discussed the research protocol via tele-
phone. During this correspondence the research
officer explained the PO programme components
and the expected role of the GP and patient in the
use of PO.
Participants and therapists
A total of 65 individuals with PD (78% of whom were
agoraphobic) participated in the study. The PO-GP
group comprised 34 participants with panic disorder
(29 with agoraphobia), including 25 females and
nine males (mean age = 37.91 years, standard devi-
ation (SD) = 10.88 years). The PO-P group comprised
31 participants with panic disorder (22 with agora-
phobia) including 23 females and eight males (mean
age = 42.00 years, SD = 11.03 years). Data pertaining
to the duration of panic disorder were obtained for
28 participants in the PO-GP group and 25 partici-
pants in the PO-P group, with a mean duration of

58.08 (SD = 66.70) and 59.07 (SD = 112.65) months,
respectively. Of the participants in the PO-GP group,
eight were taking antidepressants and four were
taking benzodiazepines. Of those assigned to the
PO-P group, 16 were taking antidepressants and two
were taking benzodiazepines.
One-hundred and thirty-two GPs from Victoria
and South Australia registered to participate as thera-
pists in the PO-GP group. All GPs were accredited by
the General Practice Mental Health Standards com-
mittee and were therefore eligible to provide FPS
under the BOiMHC initiative. Of the GPs, 37 actively
referred and treated participants in the study. The
first and second authors provided initial training for
the GPs to use PO, and regular consultative support
via telephone and email for the GPs during the
project.
Seven psychologists (six female and one male)

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