“What’s the best way to document information concerning psychiatric patients? I just don’t know”—A qualitative study about recording psychiatric patients notes in the era of electronic health records

This paper reports the results of a qualitative study regarding the main attitudes and concerns of Swiss psychiatrists related to the utility, usability and acceptability of EHR and how they address the pitfalls of sharing sensitive information with other parties. A total of 20 semi-structured interviews were carried out. Applied thematic analysis was used to identify themes with regard to participation. Three main themes were identified: 1) strengths of the use of EHR in the clinical context; 2) limitations of EHR; and 3) recommendations on preserving confidentiality in health records. The study shows variable practices of EHR use in psychiatric hospitals in Switzerland and a lack of standards on how to document sensitive information in EHR.


Introduction
Electronic healthcare records (EHR) have been used in Switzerland for several years, since a federal law on patients' electronic health records (EHR) passed in 2015 and entered into force in April 2017.
The technology aims at providing effective and high-quality care, since information exchange is beneficiary for the holistic treatment of patients, and it facilitates comprehensive evaluations and treatment planning. EHR are also used in psychiatry but raise ethical concerns, as psychiatrists often deal with "very sensitive" information about their patients (Data Protection Law; [1]. Psychiatric records often contain information on patients' present symptoms, with a descriptive narrative of their life experience, including sensitive details of possible psychological trauma, domestic violence, incarceration, sexual encounters, and substance a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 abuse [2]. Concurrently, stigma in mental health is still persistent in society which makes psychiatric patients particularly vulnerable [3]. The World Health Organization (WHO) states that mental disorders affect one in four people but psychiatric conditions are still considered as "not normal", or somewhat deviant from the norm in most societies, and many people are ashamed to have mental health issues. For this reason a high proportion of psychiatric patients practise non-disclosure of their illness [4].
Furthermore, maintaining confidentiality of sensitive data is a recurrent issue in psychiatry. Even before EHR the ethical discussion surrounding disclosure of sensitive data in the paper reports to other healthcare specialists, insurances and with proxies has taken place. For example, some studies investigated the ethical concerns psychiatrists have regarding medical information confidentiality and its potential breaching. This study has shown a variety of considerations and competing priorities, such as protecting their patients from dangerous behaviour versus maintaining relationship for therapeutic process, that are used by mental health specialists when making decisions about confidentiality [5].
The concerns regarding data confidentiality were also reflected in studies on the perception of mental health professionals toward EHR in the United States. A 2010 study by Salomon et al. revealed that concerns regarding the protection of privacy and data safety impact the quality of psychiatric records in EHR [6]. The survey stated that 70% of psychiatrists at an academic medical centre clinic agreed with the following statement: "Because of concerns with confidentiality in electronic medical records, I use more "measured" (selective, discrete) wording in the medical record". Furthermore, the study revealed that 63% of clinicians were less willing to record highly confidential information and 83% disagreed with the inclusion of their own psychiatric records among routinely accessed EHR systems. Other studies have analysed the impact of EHR on the patient-doctor relationship or focused on the time spent on "desktop medicine" (interacting with the computer) as opposed to do face to face interaction with patients. These studies reveal that EHR are a barrier for good communication and affect the quality of the patient-doctor relationship [7,8]. That being said, it should be noted that prior qualitative studies on EHR demonstrated that their use did not change the overall quality of the patient-psychiatrist relationship [9,10]. Consequently, based on the lack of consensus on the impact of EHR on clinical practice further data collection is needed in order to have a more precise overview of their practical impact and their ethical implications in psychiatry.
EHR have been used in Switzerland for a long time but there has been no study investigating how mental health specialists deal with the ethical challenges raised by its use. To this end, the current study aimed to identify the main attitudes and concerns of Swiss psychiatrists related to the utility, usability and acceptability of EHR, and how they address the pitfalls of sharing sensitive information with other parties.

Methods
Our research project, including the interview guide, information and consent forms, was approved by the competent cantonal research ethics committee (Ethics committee of Northwest and Central Switzerland, BASEC 2019-00040), and written informed consents were obtained from all participants. The individuals in this manuscript have given written informed consent (as outlined in PLOS consent form) to publish their opinions.
The COREQ checklist for qualitative studies was used to assure quality standards [11]. A purposive sample of mental health practitioners working in Switzerland was contacted by email or by phone. Interviewees comprised senior-level psychiatrists or clinical psychologists identified via teaching hospital websites in Switzerland and via snowballing based on the recommendations from other mental health practitioners. A semi-structured interview guide with open-ended questions was developed taking into account the existing literature [2,8,10,[12][13][14]. The interviews took place in Switzerland from March 2019 to April 2020 and were carried out in English and in German. The interview guide with open ended questions and a vignette was sent in advance by email. All interviews were carried out by a researcher trained specifically in qualitative methods (OC), until data saturation was reached. In qualitative analysis, the appropriate sample size is reached when no additional data are being found whereby the sociologist can develop properties of the category, a point in the analytical process known as ''theoretical saturation" [15,16]. The chosen dataset was rich enough to enable us to reach theoretical saturation for the main structural elements of the theory. The interviews lasted for 35-55 min. 16 interviews were carried out at face-to-face meetings at the interviewees' workplaces, 4 were performed online via Skype. Data analysis was performed with the use of a software (F4 for transcription and MAXQDA for coding). Interviews were transcribed verbatim and German interviews were translated to English by OC. Transcriptions and translations were checked randomly by other members of the research team. To maintain the confidentiality of participants, their personal information was anonymized as well as the name of the hospital, of the cities or cantons where they work. The usual standards of qualitative analysis in medicine were applied to the continuous content analysis of the interviews [17,18].
In this qualitative study, we reported results on answers related to electronic health records in the psychiatric setting. We aim to assess the benefits and ethical challenges of EHR and how they are perceived and handled by mental health specialists. Apart from the results concerning open-ended questions related to the experiences of participants using EHR, we also included data based on a clinical vignette. At the end of each interview, participants were asked to respond to a hypothetical case depicting a patient requesting not to report the diagnosis in his EHR (see text of the clinical vignette below).
Patient L. is a 24 years old young men, who was just diagnosed with schizoaffective disorder. You are obliged by the hospital to write the diagnosis into a common electronic database. This information would be part of his EHR (in the hospital or EHR of a private psychiatrist). The patient is concerned that it could influence his future job perspectives or insurance benefits and asks not to save the diagnosis into the electronic health record system. What would you do?
In order to systematize the results, we categorized the answers into different themes and sub-themes. We implemented inductive category development and systematic steps for data analysis, such as summarizing, explicating and structuring. 5. Experience: 17 participants out of 20 discussed utility, usability and acceptability of EHR in the hospitals during the interview. Three interviews were also excluded.
All participants except the private practitioner were affiliated with a teaching hospital. The results section is structured in a following way: First, positive aspects of EHR are presented. they raised multiple concerns regarding psychiatric patients including: 1) issues related to the accessibility of personal data in EHR, 2) multidisciplinary teams access to confidential data, and 3) writing reports and notes in EHR. Then, we observe psychiatry-related factors, which aggravate the complexity of the problem of data sharing in EHR: these are stigma in mental health, and moral dilemmas related to mental health specialists who decide either to preserve data confidentiality, maintaining patient trust, or to share it with other healthcare specialists. In light of these various challenges, participants suggested solutions on how to document in EHR and how to preserve data confidentiality, which we summarize in the tables (Tables 3 and 4). At the end of the section, we provide the responses of the participants on the hypothetical case, which was mentioned in the methods section.

Strengths of the use of EHR in the clinical context
Participants agreed that EHR render health care services more efficient and overcome problems associated with the lack of coordination within our health care system. Psychiatric patients are often treated by multidisciplinary teams (physicians, psychologists, family doctors, and caregivers), and use other healthcare services in hospitals. In addition, participants thought EHR help optimise treatment of the patients by having a quick access to medical information from different parties.

Limitations of EHR
Most participants also mentioned limitations related to EHR, especially regarding data sharing (n = 19). However, the issue was perceived differently in each hospital, as hospitals throughout Switzerland organize psychiatric files in different manners and, according to our interviewees, practices might even vary within the same hospital. Several participants reported that their hospitals have implemented a special protection system within their EHR, which allow the doctors from non-psychiatric departments to access the patient files under specific conditions, such as providing expert advice or emergency care. Furthermore, it was mentioned that some hospitals restrict access to the information within a one department, so that only doctors involved in the treatment of a particular patient can see the record.
"Access to the patient files is actually allowed only for those who are involved in the treatment. Theoretically, as a medical director, I have access to everything, but otherwise it [the access] is limited to people who are working on the case. We also monitor that non-authorized persons do not have access to this data." (P16,HP,G) Interviewees also reported that in other hospitals, psychiatry departments have technical barriers that do not allow clinicians to share patient files with other departments, despite being part of the same hospital. These limitations prevent access to the medical files even in case of an emergency.
"We, as a psychiatric university clinic, here in [city] practically never share our data with the somatic departments within the hospital, even during an emergency, there is no possible access.." (P10,HP,G) All mental health specialists mentioned that EHR enhance the risk of data abuse, breaches in confidentiality and privacy, and inappropriate record sharing (detailed description is provided in Table 2). Many participants (n = 6) have reported keeping separate notes apart from the EHR.
"Every time I see a patient, I enter a note in the system, stating that I have seen the patient today, and I will also note if I changed the treatment, the medication, or if I specified some condition, for example "not able to work", or if something major happened. But I keep all the patient's personal information on paper."(P6, HP,F) Most participants disclosed that they are often facing constraints between data sharing and data protection while writing their reports in EHR. The main reason in favour of protecting data in psychiatry is the nature of the issues discussed with psychiatrists or psychotherapists. The information is often very personal and sensitive: patients disclose to therapists their internal conflicts, which refer not only to them, but sometimes also to their proxies, such as family problems and interpersonal difficulties. The sensitive nature of the information is, according to the interviewees, the major challenge in psychiatric documentation as exemplified by the following statement: "Health data in each area of medicine is sensitive, but in psychiatry, these are special data, which sometimes contain a whole life story of the patient and involve a family history[. . .] And, of course, such information is very explosive data, if this kind of information fell in the wrong hands, the outcomes can be incurable." (P15,HP,G) Also, some intricacies mentioned by patients and the patients' interpretation of their past situation and emotional aspects are difficult to document. Subjectivity in the interpretation of data was pointed out as another particular attribute of the information communicated in mental health care. This is a particularly challenging issue in psychiatric documentation as the information has meaning for the patient and the therapist, but it may not always be objectively truthful.
"Sometimes there is an uncertain information, for example, when the patients say that they are not quite sure that the event actually happened in childhood. So, you do not even know if that occurred in the past, but that is now written in the record." (P5,HP,G)

Mental illness and stigma
Participants (n = 6) highlighted that stigma is an ever-present issue within mental healthcare, and that it should be considered when information regarding psychiatric consultations is  Several participants (n = 4) raised concerns about mental illness-related stigma in relation to other health care professionals. Indeed, there is a concern that other health care professionals can access the EHR data which could negatively affect the quality of care psychiatric patients will receive in a non-psychiatric department.
"We know that psychiatric patients are often poorly cared for in somatic medicine because they have psychiatric diagnosis." (P4,HP,G)

Trust and transparency
Data sharing between health specialists is beneficial to the patient. For instance, physicians in the emergency department can make an informed decision taking into account relevant information regarding mental health disorders that may affect their patients. In many situations, for safety reason, it is important to know the patient's medication to avoid unsafe medical interactions. The more information physicians have about a patient, the more precise the diagnosis and treatment options will be. Ultimately, the process will result in higher quality of care and overall well-being of the patient.
"I'm treating that patient, and if the patient is going to the emergency room, for the doctor there it's important to know, that this patient is treated in my service for this and this, and receives such medications." (P5,HP,G) The therapeutic alliance is a key component in psychiatry. Building a proper connection requires transparency from both the patient and the mental health specialist. "In psychotherapy the relationship is the major component of the treatment. The quality of the relationship you

Lack of clinical guidelines, lack of agreement
As highlighted by the participants, EHR technology allows for quicker access to medical files by health specialists. Unfortunately, this technology has also some limitations as it may compromise the confidentiality of sensitive data. Consequently, the data security and privacy risks influence the writing of medical documentation. Our study has shown that the balance between data sharing and sensitive data protection remains a personal choice in the Swiss psychiatry setting. Each participant provided an individual "solution" on how to deal with the mental health information of patients. In the array of opinions, participants differ concerning the type of information and the degree of detail they considered indispensable to be recorded in their EHR. In particular, they criticise the lack of standards for documenting EHR. Many participants agreed that excessive information is unpractical. Thus, there is a need to prioritize the information according to its clinical relevance. However, even psychiatrists from the same clinic seemed to use different approaches. Common strategies chosen by several participants were "to write less and in common phrases (for example, naming the disease class "mood disorder" instead of "depression"), or to record the information strictly useful for treatment. For others, it was still important to record detailed information (See Table 3) As mentioned above, the majority of participants perceived maintaining confidentiality of psychiatric diagnosis as the major challenge of the EHR. Participants provided several solutions for dealing with the privacy issues related to records.

Vignette, a confrontation between obligation to record properly and patients' will
Some participants (n = 4) mentioned that they often faced the situation of patients not wanting to have their diagnosis recorded in the EHR. They stated that many patients wish to keep some information about their mental health condition private.
"It happens from time to time that patients say, "I wouldn't like that you documented something about it"."(P2,HP,G) "The problem, when the patient says, "please do not write down this diagnosis", we already have that [a lot]. I always have younger patients who are diagnosed with schizophrenia and who then sit here and say, "Dear Dr., please call it "depression", or "anxiety disorder", but just not "schizophrenia". Because it is in the files of the university hospital and then I apply for a place to study, or for a job, or go abroad, for money and funding, then somebody would read,." (P5, HP,G) There were two main approaches to solve this dilemma: The majority of participants would prefer to save the diagnosis into EHR and to convince the patient to accept it. The mental health professionals interrogated mentioned that precise information will help other doctors provide a better treatment for the patient. Consequently, the patient would directly benefit from it figuring on the EHR.
"Of course I would discuss with the patient that there are also potential advantages if other doctors know that he has this disease, because then they will be more aware, for example, of his medication. There are risks when other doctors don't know that he is taking particular drugs. Moreover, they may be able to choose a treatment for the patient more individually." (P9, CP,F) Another reason in favour of documenting the diagnosis was that they needed to justify the treatment to insurance companies for reimbursement purposes.
"I have to make the diagnosis because then the health insurance company will cover the treatment." (P2 HP,G) Some interviewees stated it was their professional obligation to write a proper diagnosis or that they did not see an alternative to what they define as a duty of care.
"I think I have an obligation, so I would not document it wrong. If his condition meets clearly the diagnostic criteria, I would document it and demonstrate to the patient that he has the right, that we are under confidentiality and that there is no way out of this documentation." (P10,HP,G) Alternatively, some participants took into account the wish of the patient and considered the use of an "umbrella" term, i.e. a more common term for the group of diseases, instead of writing the precise diagnosis.

Discussion
In this section, we discuss EHR in a context of the Swiss healthcare system and analyze the problems mentioned be participants. Then we outline the ethical issues associated with sharing sensitive data in the electronic patient dossier (EPD).

Electronic hospital records
This study provides a unique perspective of variable practices of EHR use in psychiatric hospitals in Switzerland. To our knowledge it is the first qualitative study examining the perceptions of Swiss mental health specialists concerning EHR and their attitudes toward documenting mental health care in electronic medical records. As electronic documentation of mental health care raises ethical challenges worldwide, our findings are also relevant for other countries where EHR are widely implemented, such as North American and many European countries, [19,20].
EHR have been utilized in many Swiss psychiatric hospitals, Whereas all hospitals were federally obliged to use EHR, the voluntary expanding of EHR on ambulant healthcare has evolved in different ways. In St. Gallen, Vaud and Zürich hospitals played the pivotal role in spreading EHR networks. In Geneva the patients were directly encouraged to use EHR and to have access to their data. Both approaches were shown to be successful strategies in attracting HCP in 2017. In Ticino, however, oncology private practices were reluctant to join EHR due to concerns about data sharing with patients [21] Nowadays, all hospitals and two thirds of ambulant healthcare professionals work with EHR [22], which are integrated in the overall healthcare system due to their advantages such as accessibility, accuracy and readability of records, long-term archiving, structured medical files, and limited risk of data loss.
Along with these benefits, there are still many unsolved problems in EHR implementation that deserve careful attention, such as risk of data abuse, explicitness of the informed consent, data protection, and data ownership. The issue of data protection and data confidentiality has already been discussed in other studies [23]. However, the problem of confidentiality is more prominent in light of the high emphasis on privacy in Western societies, including Switzerland. Also, many participants spoke about stigma around mental health conditions, an issue encountered in the clinical context as well as in the daily life of patients.
The struggle between ensuring the good of the patient by sharing medical information and preserving privacy and confidentiality is a recurrent problem in psychiatry. With EHR the trade-off between benefits and risks of data sharing is getting even more problematic because medical data is accessible by many parties. The quick and ubiquitous access to medical information through EHR, aimed at promoting the good of the patient, has a potential danger of stigmatization and consequently of lowering the quality of medical care. First, studies have shown that medical staff may treat psychiatric patients in a different way due to stigmatization [24][25][26]. Second, EHR may increase the risk of what Jones and colleagues call "diagnostic overshadowing", when physical problems are misinterpreted due the documented psychiatric state. This problem can lead to underdiagnosis and mistreatment of the physical conditions in psychiatric patients [27].
Most participants mentioned their desire to protect patients' privacy by the particular way they use EHR to document patient care. In our study, we observed a lack of consistency in documentation among healthcare providers in Switzerland which seems to be caused by the absence of guidelines specifying how to document mental health information. It is also important to mention that the EHR records may also have potential legal implications and be used in court in some cases. By law, doctors are obliged to write a correct diagnosis [28]. Only those medical procedures or assessments, as well as therapeutic discussions which were documented in the health records matter for the court. Lack of information in the record or incorrect information on a patient's history of abuse, or assault can have negative legal consequences for the attending doctor. However, this issue is beyond the scope of this paper. Our results from Table 4 and the vignette show the existence of a large variety of ways of recording information in the EHR. In order to protect patients' privacy, some participants suggested sticking to more broad information regarding the patient's mental state in the diagnosis register. In contrast, other healthcare workers provided reasons for detailed documentation of mental health concerns, such as transparency, collegiality or issues related to reimbursement by insurances.
Prioritizing medical information by clinical relevance was suggested by many of the interviewed mental health specialists. For example, there seemed to be general agreement that medication must be reported as some psychotropic drugs may cause side effects and dangerous pharmacological interactions with other medication. Information from previous treatments can be of utmost importance in predicting the patients' responsiveness to future prescriptions. Thus-although by documenting medication doctors provide direct or indirect indications about the diagnosis underlying their prescription-the benefit of knowing about medication definitely outweigh privacy concerns. As the relevance of other information in the psychiatric record is less certain and more difficult to anticipate, interviewees varied in how they document other types of information.
Participants raised the issue concerning the impact of documentation on trust and transparency in the psychiatrist-patient relationship. From the interviews we conclude that there is no general rule recognised and followed by all psychiatrists that they should be transparent with their patients regarding what and how they document information in the medical record. Our study indicates instead that there are many individual preferences on how to document into the EHR without patients being systematically informed about these variations. This can be problematic since a lack of transparency on this can negatively impact therapeutic relationships, creating mistrust of mental health patients towards the care system and their HCP.
Moreover, EHR at the hospitals may be considered as a limiting factor for patients concerned about the privacy of their mental health condition data. These patients may seek help elsewhere, fearing stigmatization by other HCP due to their documented psychiatric condition. If patients perceive that they don't have any choice ("I'd say to the patient: either he doesn't come to the hospital and then he will not have EHR and if he decides to come to the hospital, he has to accept that he has to have an EHR." (P19,HP,F)), EHR can become a barrier, refraining them from consulting university hospitals and pushing them toward a certain type of private practices that still use only paper records.
To address the constraints between data sharing and data protection while using EHR in psychiatry, participants suggested a range of solutions: better regulation, heightening doctors' responsibility, obtaining a purpose-related informed consent for saving sensitive information in the record, or limiting access to the information. Some participants mentioned that the EHR content is an issue better openly discussed with the patient, which is exactly the idea behind the Electronic Patient Dossiers (EPD) initiative.

Electronic patient dossier and future challenges
Following a new federal law adopted recently by the Swiss parliament, all hospitals in Switzerland should implement the so-called Electronic Patient Dossier (EPD) by 2021, a technology which grants patients right to assign and adapt the level of visibility of their medical information to specific health professionals, and to access and record their own data in an electronic file [29].
The EPD incorporates some of the solutions suggested by our participants. For example, it includes "limiting access to the information in EPD", "purpose related informed consent" and "better regulation", which implies the possibility to provide different levels of data access to each stakeholder.
A survey in 2020 showed that while 90% of public hospitals support implementation of EPD, only 52% of HCP in private practices would like to use EPD [30].
While adoption of EHR was voluntary for ambulatories and private practices, all certified medical professionals should adopt EPD according to the Motion 19.3955 [31], so that all ambulant care will be included in the system. The practical implementation of EPD in Switzerland was postponed due to many factors. There is a high institutional and organizational fragmentation of the Swiss healthcare system, which exists both at the institutional level, with 26 Cantons regulating the health system and a limited stance for national policies, and at the organizational levels, with many independent healthcare providers serving the same population and the strict separation between the health insurance companies and the health services providers [21,32]. The responsibility to develop EHRs was left to Cantons or providers networks, which resulted in the formation of different EHR systems. This process created a need of harmonization of the documenting standards as well as technical requirements of health records for EPD. Consequently, a huge administrative change is needed. The hospitals have to agree on documentation standards and to adjust their EHR systems according to the technical requirements for interinstitutional data exchange. During the transition, some private practices should use double records (hand-written and electronic). The costs for this time and effort are not yet covered by the Government [22].
Protecting sensitive data in a complex chain of multiple healthcare providers can be problematic and requires secure technologies and procedures. In order to warrant data privacy within such a complex system as EPD records all healthcare providers are supposed to be united under the so-called "circle of trust", and each healthcare provider is obliged by law to obtain conformity in terms of data privacy and data protection [33].
The solution of "patient participation", as suggested by the participants in our study, is also present in the EPD. The EPD is oriented towards patients' autonomy as it makes patients the custodians of their medical records. They can subsequently grant access to their medical information to HCP. Some interviewees critically contemplated such approach, because it transfers greater responsibility to patients with mental health disorders, including those with altered decision-making capacities (during moments where capacity is present) and their representatives. The EPD is sometimes perceived as problematic for mental health care as patients can restrict access to some of their information to health specialists, without necessarily understanding its medical importance. In that case, they are held accountable for the consequences of their choices. As one participant reported (P13,HP,G), it is "good that the patient can determine who has what information" because that" implies that the patient then has more responsibility". The risk is however, that if "a wrong decision happens based on the missing information, and let's assume the patient has also considered something and thereby the decision is made that was not the right one" the responsibility transferred to the patient might be inappropriate and cause harm as the patient is "a medical layperson" and cannot determine what is important and will cause benefit or harm in the same way as a doctor can. For HCP it is often difficult to understand why patients would not want to share important information with doctors. HCP might underestimate risks to privacy and feel upset ("What is so important that the doctor can / should not know" (P13,HP,G)) thinking that patients accuse them in a non-justified way.
Based on the idea of an overriding concept of beneficence, the federal law on the EPD stipulates that in medical emergency situations healthcare professionals can get access to the medical data of the patient, even if the patient restricted access rights [29]. The EPD has thus been conceived as a possible way to solve the ethical conundrums posed by the EHR, i.e. by regulating data sharing on different levels. Nevertheless, it might create another set of issues such as a greater concern on confidentiality due to cross-institutional data exchange, and increased responsibility on the part of patients for sharing their data with other healthcare specialists.
The development of EPD and EHR also raises the question of dealing with a temporary alteration in the capacity to consent and decision making that is typical for numerous mental health conditions, e.g., schizophrenia, major depressive disorder with psychotic features, manic disorder with or without psychotic features, etc. In such situations, if patients have greater access to their medical data, they may-in a moment of decreased capacity-disclose sensitive information on social media, i.e. act in a way they would not condone when fully capable.
The latest ''shocking" hijack of psychotherapy records in Finland is yet another example of events that make patients and mental health care professionals alike nervous about thorough documentation in any electronic form [34]. With the increase of ransomware and data breaches, the relevant question of cybersecurity and thorough data encryption must also be taken into account in acquiring the patients trust into any kind of electronic health data documentation, including the EPD and EHR.
Since the sensitive information can be shared with many stakeholders in EPD, the discussion on how to document sensitive psychiatric data is going to gain even more significance for standardization of health records.

Limitations
This research is subject to several limitations. First, we have interviewed participants in the French and German parts of Switzerland, so the results may be not generalizable to the whole country (which also includes an Italian speaking part). Second, the responses of participants could contain bias of social desirability which could mean that that practices deemed problematic were underreported. However, the fact that we found a high variability of attitudes, some more problematic than others, is an indicator that we were able to picture many facets of current practice, and that the bias of social desirability remained low. The study drew on data that were gathered at a point in time in a rapidly evolving landscape of development of healthcare IT technologies and we cannot guarantee that participants' attitudes might not have changed since the interviews took place. Finally, we have reported only on a subsection of topics addressed in our interview guide. The guide was not focused specifically on EHR, but also included structured questions on EPD and mobile apps for psychiatry. However, the responses indicate data saturation on the main themes that we report here.

Conclusion
The digitalization of psychiatric records is a source of many controversial ethical issues as exemplified in the use of EHR and EPD since the information in these records is particularly sensitive. It is important to recognize and discuss them openly and our study has the merit to make this discussion better visible.
Our research revealed a panoply of competing opinions of Swiss mental health specialists on how to document in EHR. This reflects the various EHR systems in the fragmented healthcare system in Switzerland. There is a need to reflect further on these practices. It is important to ensure that health professionals are trained in the process of ethical decision-making involved in dealing with sensitive information in the medical record. Furthermore, ethical standards for the documentation of mental health conditions in EHR and EPD should be openly discussed and there is a need for more explicit professional guidelines. Patients' participation seems to be a very promising approach for a patient-centred care paradigm in psychiatry. Nevertheless, it imposes greater responsibility for patients who can actively manage and share their health information in cross-sectoral care and this could be problematic for the vulnerable group of patients needing mental health care. Sensitivity to the needs of this vulnerable group of people needs to be heightened when creating the future regulations on EHR and EPD. It will also be important to provide training for the mental health patients on using EHR and EPD and on how to manage confidentiality risks in an efficient and transparent way.
The recent COVID pandemic showed the importance of quick access and interoperability of data for clinical care and research, therefore EHR and EPD may positively affect healthcare efficiency. Introduction and harmonization of EHR and EPD in decentralized health systems can be problematic. Whereas some countries, such as Austria or US [35,36], provide financial incentives to accelerate EHR adoption, currently in Switzerland there exist no such support mechanisms.
The need to protect patients' sensitive information is of great importance in the Swiss healthcare system. The discussion on what and how to document sensitive data in EHR and EPD requires the right legal and technical framework to harmonize the fragmented health care system. This experience may be of use for decision-makers in the other countries.