Parents Need to Pay Attention to Adolescent Healthcare in the Military Health System

'Why am I blocked from my 12-year-old's online medical record?' and other curious practices revealed.

Screenshot of what parents see in the Tricare Online Patient Portal when accessing records of children 12 and older

I’ve recently done a deep dive into the world of adolescent medicine within the military health system (MHS). While it might seem like this deviates from the topic of education, it’s actually related because our adolescent children are learning about how to grow into healthy adults—and our health practitioners can either help or hinder that process. In the realm of adolescent care, which has emerged as its own board-certified subspecialty over the past thirty years, I wanted military parents to be on the same page about the push for increased adolescent confidentiality—and all that entails—that occurs when their children turn 12. California parents already live with the practices I’m about to explain (and so do parents in states like Washington and New York), but I was blindsided to learn that MHS has gone down the same path.

It wasn’t always like this. In 2017, the Defense Health Board (DHB), an appointed Federal Advisory Committee that provides advice to the Secretary of Defense, acknowledged in its report on Pediatric Health Care Services that the emerging field of adolescent medicine had “recently made a profound shift from its traditional role. Instead of providing preemptive guidance to parents, providers now work to reduce risk-taking behaviors with their focus aimed directly at the adolescent.” [emphasis added]

Below, I will share information that I believe all military parents should be aware of:

1. Parents are barred from accessing their children’s electronic health records (EHR) (except for immunizations, vitals, and allergies) once a child reaches 12 for the Tricare Online Portal, and at 13 for the new MHS Genesis system. However, while 12-to 17-year-olds are expected to begin managing their own healthcare, they cannot have their own password to the online portal, and they must be 18 to open their own account. Though the Defense Health Agency (DHA) states that “DOD Policy and COPPA” are the reasons behind this blanket block on parents, no one within MHS, Tricare, DHA, or the Department of Defense (DOD) has provided me with said DOD Policy or how the law justifies it (and I made my initial ICE Comment in December 2022. I filed a FOIA with DHA in February, but I’m told I won’t have an answer till April, and I opened up casework through my U.S. Senator to find an answer). Parents can still ask for copies of the medical records that can be emailed, but wouldn’t giving parents access to online records save a lot of time and energy, especially between duty stations? I thought electronic health records were supposed to make our lives easier.

2. EHR systems are difficult for doctors to navigate when it comes to adolescent privacy because of differing state laws, HIPAA compliance, and the Final Rule for the 21^st Century Cures Act. In addition to state and federal laws, medical societies like the American Academy of Pediatrics (AAP) and Society of Adolescent Health And Medicine (SAHM) have established their own “best practices” for medical care for adolescents. The authors of State-by-State Variability in Adolescent Privacy Laws write, “Health care providers instead of policy makers and politicians, should be the ones determining privacy and confidentiality regulations for adolescent patients.”

   An article from AAP that specifically mentions the complexity around keeping abortion and transgender care for young people confidential echoes the same sentiment that health care providers know better than law makers and recommends supporting “ongoing efforts to develop technical methodologies for granular segmentation of digital health information in EHRs so that sensitive information can, when ethically or legally necessary, be protected from sharing” and “for the health care community to work on developing recommendations for what would optimally be included in laws that protect adolescent minors’ privacy consistent with ethical standards and best practice professional guidelines, while allowing advocates in each state to decide whether and when it would make sense, without undue risk, to move forward with efforts to bring the laws in their state in line with the professional recommendations.”

   In other words, this AAP publication is promoting additional efforts to develop technology to make it easier to hide sensitive digital health information from parents and to codify the current practice of restricting parents from accessing adolescent EHR that may not be covered by laws in every state.

   In accordance with these efforts to develop technology, some of the professional literature mentioned the existence of adolescent modules within an EHR system. Just such a system is noted in a 2019 Contemporary Pediatrics Journal article that states that some EHR systems “can be configured such that all adolescent notes are written in separate confidential notes that trigger a warning when accessed, indicating to the viewer that the information contained therein is provided on a ‘need-to-know’ basis.”

   Additionally, the California School-Based Health Alliance, an advocacy organization that works to expand school-based health care, reveals in its online resources that some school-based health centers already have the capabilities in their EHR to segment information, thereby keeping it confidential from parents.

3. Parents of adolescents are asked to leave the exam room during well child checks so that a psychosocial assessment can be performed. It is often presented as a “requirement” that parents leave, but it appears that this “requirement” is only based on guidelines from now highly politicized professional organizations like the AAP. Researchers in 2016 found from a nationally representative sample that in most medical practices 50% of visits included alone time. But that figure jumped to almost 100% incorporation of one-on-one time in adolescent clinics where providers had fellowship training in this subspecialty.

   One tool that doctors use for the psychosocial evaluation within MHS and the civilian world is the HEEADSSS assessment. HEEADSSS stands for: Home, Education and Employment, Eating and Exercise, Activities and Peer Relationships, Drug/Cigarette/Alcohol Use, Sexuality, Suicide and Depression, and Safety (and sometimes Spirituality), and it was updated in 2014 to take into account media use. You can access a detailed explanation of the HEEADSSS assessment and suggested questions in The Psychosocial Interview for Adolescents Updated for a New Century Fueled by Media written by U.S. military-associated doctors. Some of the “potential first-line questions” under “sexuality” are: “Tell me about your sexual life. Are you attracted to boys? Girls? Both? Not yet sure?” If time permits or the doctor feels the need to dig further, here are some follow up suggested questions: “Are your sexual activities enjoyable?” “How many sexual partners have you had altogether?” “What are you using for birth control? Are you satisfied with your method?”

4. Parental rights are treated differently depending on the state, so as families make military moves across the United States and overseas every two or so years, they should be aware that though the Health Insurance Portability and Accountability Act (HIPAA) gives parents access to their children’s medical records until they turn 18, it cedes this privacy rule to state law. But state laws on minor consent and confidentiality vary significantly when it comes to how much sensitive health information will be shared with parents. So, for example, California’s laws allow a 12-year-old to obtain an abortion, and no parental involvement or notification is required. Florida, on the other hand, requires minors to notify at least one parent 48 hours prior to an abortion and permission must be given—though a judge can bypass this.

5. Today, adolescents can receive confidential care on military bases and in school-based clinics across the United States. For example, The Adolescent and Young Adult Medicine clinic at Naval Medical Center Portsmouth near Norfolk, Virginia, provides health care for dependents ages 12 to 26; this includes gender affirming care, confidential contraceptive care, confidential sexual health care, and confidential mental health care.

   Another example is Joint Base Lewis-McChord’s Madigan Army Medical Center’s adolescent clinic that offers subspecialty care for gender identity concerns, sexuality issues, and substance use, among other services. On the adolescent clinic’s web page, it links to a document that explains the health care rights of minors in Washington state. Unemancipated minors can receive services for abortion at any age without parental consent. They can be tested and treated for sexually transmitted diseases without parental consent, generally beginning at 14, but in Seattle and King Counties, they will be tested/treated at any age without parental consent. At 13 years of age, minors may receive outpatient mental health services without parental consent, and parents cannot be notified unless the child consents; and at 13 years of age, they may seek inpatient mental health services without the consent of parents, but parents must be notified. Beginning at 13 years of age, they may be seen for outpatient substance abuse, and parents are only notified if the child consents or a doctor determines it’s necessary.

   In addition to its adolescent services on base, Madigan also runs a system of school-based health clinics in 10 area middle and high schools. Military dependents who have Tricare Prime insurance can visit the clinic once each week.

   But at-school health care isn’t just for middle and high schools, Ft. Belvoir Community Hospital provides embedded child health care at Ft. Belvoir Elementary School through a combination of its School Behavioral Health Program and Pediatric Behavioral Health Primary Care. Providers “deliver 1st line treatment and coordinated care for child and adolescent behavioral health concerns” and are also embedded within Ft. Belvoir Community Hospital’s Pediatric and Family Medicine Departments.

So, there you have it, please share this with any military friends/family that you know. It’s important that we all know what’s happening in adolescent healthcare and why it’s happening so we can continue to do our jobs as parents.

Also, if you have a story to share in regard to MHS adolescent medicine, please send me a message at amy@theprimaryeducator.com.

You can expect more to come on this issue after I receive answers from the federal government!