Objectives

Discuss the ethical appeals that ground a right to confidentiality Discuss the ethical guidelines for disclosing confidential information Name the federal and state confidentiality laws that are relevant to pharmacy practice List the four exceptions to confidentiality under HIPAA Identify actions that breach confidentiality in pharmacy practice

Overview

Ethical and legal consensus on confidentiality

Inappropriate disclosures and inappropriate access Case discussion

Ethical Grounding of Confidentiality

Appeal to trust

Without trust that health care professionals will maintain confidentiality, patients may be less willing to: Seek help Share relevant information Comply with a treatment plan

Appeal to respect for autonomy

Patients have a right to decide with whom to share personal information

Ethical Grounding of Confidentiality

Appeal to fidelity

Implicit or explicit promises of confidentiality

Appeal to respect

Recognizing and being sensitive to patient vulnerability Preserving patient dignity

Codes of Ethics

A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacy technician respects and supports the patients individuality, dignity, and confidentiality.

From the APhA Code of Ethics and the AAPT Code of Ethics for Pharmacy Technicians

Ethical Guidelines for Disclosure

The communication should be necessary and effective for good patient care The risks of breaching confidentiality are proportional to the potential benefits The alternatives for communicating the information are impractical The communication practice should be transparent (in the sunshine)

HIPAA

Federal law that provides a minimum standard for privacy by restricting the use and disclosure of protected health information (PHI)
One of the motivations for passing HIPAA was targeted marketing by pharmaceutical companies

PHI Disclosures Under HIPAA

Permitted disclosures

Those required for treatment, payment, health care operations Disclosures authorized by the patient

There are numerous gaps in the regulations that are appropriately filled by professional judgment and ethical guidelines

Texas Confidentiality Laws

Texas law has explicit laws regarding physicianpatient communications but defers to HIPAA and other general medical record privacy laws in the case of pharmacists and pharmacy technicians

Exceptions to Confidentiality

Required Disclosures

Abuse (child, elderly) Injuries such as gunshot wounds Reportable communicable diseases
Patient consent Surrogate decision maker when patient is incapacitated (includes minors) May warn police in case of imminent physical threat to self or others Legal proceedings Others involved in patients care

Permitted Disclosures

Reportable Communicable Diseases

Includes STDs (especially including HIV)

A health professional (which includes pharmacists and pharmacy technicians) shall report to the local health authority a suspected case of a reportable disease and all information known about a person who has or is suspected of having the disease if the persons physician, lab director, etc. has not already done so.

Inappropriate Disclosure

You are working on a prescription for a patient who has an embarrassing bowel condition and the patients name sounds familiar. You realize that the patient is a co-workers ex-boyfriend. They didnt part on good terms and so she laughs when you tell her about his plight.

Ask yourself

Is sharing the PHI necessary for the patients treatment, billing or hospital operations, or has the patient authorized the disclosure? Is sharing the PHI a required or permitted disclosure?

Cousin Billy

Your cousin Billy, who is a close friend of yours, is in the hospital and, purely by chance, you find yourself filling his prescription. The prescription is for AZT, an antiretroviral drug for treatment of HIV. You did not know that Billy is HIV+ and you are concerned for his girlfriend, Tracy. You visit Billy later and ask him if Tracy knows. Billy is adamant that Tracy not know his HIV status and insists that he is careful.

Handling Cousin Billy

Texas law allows a persons HIV+ status to be disclosed to his or her spouse, but not a girl- or boyfriend

Are there hospital resources such as chaplains, social workers or others who might also talk to Billy?
Texas Partner Notification Program

Accessing Records

When anyone not involved in a patients care, billing or hospital operations accesses the patients medical record, confidentiality has been breached

This includes hospital employees, physicians and others who have wide-ranging access to patient records This is true even if the person does not share the information in the chart with others

Inappropriate Access

You have learned that one of your co-workers fell ill over the weekend and was admitted to the hospital. Curious about his ailment, you check his record to see what hes taking.

Ask Yourself

Do I need this information for the patients care? Is this information I would legitimately have access to anyway?

Your minor childs record Your own record

Princess Magdalena Vanessa

You are shocked to hear that Princess Magdalena Vanessa of Elvefal is a patient in the hospital. Your parents immigrated from Elvefal and you have grown up hearing about its royal family. Your whole family celebrated the Princesss marriage to Prince Nicolas Magnus last year. You are deeply concerned about the Princess, especially since there have been rumors that she is expecting. You want to check her chart to see if she is OK.

The Princesss Records

If you do not need access to a patients record for treatment, billing or hospital operations, it is inappropriate to access the patients record without the patients authorization.
This is true even if you want to access the record out of concern and not out of curiosity.