Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, December 24, 2006

HIPAA vs. Community

I have always been a stickler for patient confidentiality. From the moment I hung out my shingle I refused to use a sign-in sheet. (The tenth patient of the day had no business knowing who else had been in.) I trained my staff not to holler out patient names if there were other patients standing around. I also practice what I preach; I'll bring a chart to them and point to the name while saying "This lady is on line 1 and needs an appointment." Even the fact that someone is my patient at all is potentially sensitive. Although I do my best to jump through all the HIPAA hoops, I tell my patients, "Here are my 'privacy policies': I won't tell anyone anything about you unless you say I can in writing."

On the other hand, when patients discover how wonderful you are, one of the good things they do is rush out and tell all their friends, neighbors and family members all about you. And in the fullness of time, many of these friends, neighbors and family members come in and comfirm for themselves that you are, in fact, wonderful. So what happens is that you get to caring for clusters of people: family groups, neighbors, office mates and entire aerobics classes all become patients. I've lost track of how often I hear the exclamation from the waiting room, "I didn't know you come here!" While there are certainly busybodies and gossips out there, many of these community groupings are people who care deeply about each other and are entwined in each others' lives. It is my opinion that blindly following the letter of the HIPAA laws is not only unnecessary and unreasonable, but is detrimental to the care of our patients in the context of their communities.

Example 1: First Monday morning patient is standing in front of me signing in for her visit. (Her diabetes is under great control with her 55 lb weight loss, but she always bring us cookies or doughnuts when she comes to visit. Not the crappy ones that are easy to pass up either; the rich butter cookies with the sprinkles, or the chocolate covered miniature doughnuts -- the ones that are impossible to resist.) The phone rings; Mrs. A has a cold and wants an appointment. We set one for later today. Then she says, "Did you hear that Mr. B passed away Saturday night?" Mr. B is a hospice patient of mine who happens to attend the same church as Mrs. A, who has frequently made remarks on previous visits about him. It seemed rude -- not to mention pointless -- to be coy about knowing Mr. B, so I felt comfortable enough with polite responses acknowledging the relationship. (Also, as it happens, the hospice had somehow screwed up so that the last doctor to discharge him from the hospital had somehow become the physician of record, so that was who'd been called.) So I got to say to Mrs. A, "No, I hadn't. But thanks for letting me know." (It also came in handy later in the day when we got a call from the funeral home to sign the death certificate. I punted it over to the other guy.) I jotted Mr. B's name down on a post-it, planning to pull the chart and call his wife later.

Wonderful Staffer #1 walked in about then, saw the post-it and exclaimed (yes, in spite of her training; WS1 isn't quite as tuned into the subtleties as WS2) "Mr. B passed away?" Whereupon Cookie-or-doughnut lady said, "Mr. John B?" Whereupon I recalled her having previously told me about her friendship with Mrs. A. She too knew Mr. B, but had not heard of his passing. A group of caring people moving in the same social circle; I refuse to view this "HIPAA violation" as a bad thing.

Example #2: A lovely gentleman in his early 80s with six children, of whom four are my patients and two of whom bring their entire families to me. Although sharp as a tack, he had hearing problems for decades, and sometimes had difficulties recalling what I said at visits and questions he had intended to ask. His two daughters (the ones whose families I see; one of whom works for a local orthopod) were very close to him, and he frequently asked me to call them to schedule his appointments. When he was diagnosed with a colon cancer recurrence (to which he eventually succumbed) information was often given at "family conference" visits. Even on those occasions where I essentially informed one of the daughters of a test result before telling the patient, I knew it was ok with him. Not only did he never express any dismay at my having done so, he told me several times that he wanted them to know first so they could help explain things to him. It was truly "Family Practice" in the most rewarding sense of the term.

Then again, this community thing can be hard to get away from. I went to my local big box hardware store to look at some doors for my living room at home. The above referenced gentleman's oldest son (also my patient) was in charge of the doors department. He wrote up our order for unstained pine French doors with lovely bevel cut glass windows and arranged for the installation. No problem.

A week later his sister -- the one who works for the orthopod -- came into the office for a BP check and said, "What kind of doors did you get?" We discussed the various color options of urethane stain under consideration.

The following week their mother came in for blood work to monitor her lipid medication, whereupon I was treated to a very informative discourse on the relative merits of rag vs. brush for applying urethane stain to unfinished pine. (Rag: much easier to apply the stain evenly, for a nice uniform finish.)


At Mon Dec 25, 04:25:00 PM, Blogger Bo... said...

It's the same here in Podunk. One time a patient asked me if I "knew that Mr. so-and-so was in the hospital". I lied and said: "No, I didn't know" for HIPAA/privacy reasons. To my embarassment, the patient retorted: "You didn't? Well then how come I saw your car there yesterday just before he went to the hospital?"

At Mon Dec 25, 05:14:00 PM, Blogger Janet said...

I once worked in a dialysis unit where most of the techs were related to, lived in the same neighborhood, or went to church with most of the patients. Privacy? There was no such thing.

At Tue Dec 26, 04:55:00 PM, Blogger Richard A Schoor MD FACS said...

Congtratulations on having what seems to be a wonderful practice, one which I aspire to achieve. And I agree with HIPAA and plan to do away with my sign in sheet at once!

At Wed Dec 27, 05:36:00 PM, Anonymous Anonymous said...

When I had physical therapy a year ago, the therapists weren't able to talk about any other patients who were there getting PT at the same time. Such as, if I asked a therapist if another patient had the same type of injury I had, she/he couldn't tell me anything about the other person. But we patients were allowed to talk amongst ourselves about our conditions. Which made for some not-very-private conversations, when patients would talk out loud to each other, sharing lots of details, that anyone within earshot could hear.

My therapist was able to talk to me about former patients who had the same condition I had, of course without mentioning their names or going into too much detail.

At Fri Mar 30, 04:15:00 AM, Anonymous Anonymous said...

Hey I really think that HIPAA's rules and regulation had made a significant impact on healthcare organization, physician and practitioners and other entities who do falls under HIPAA compliance in keeping the patient overall health information secret and not disclosing it even at any point.


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