Objectives

1. 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

2. Overview • Ethical and legal consensus on confidentiality • Inappropriate disclosures and inappropriate access • Case discussion

3. 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

4. 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

5. 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 patient’s individuality, dignity, and confidentiality. From the APhA Code of Ethics and the AAPT Code of Ethics for Pharmacy Technicians

6. 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)

7. 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

8. 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

9. Texas Confidentiality Laws • Texas law has explicit laws regarding physician-patient communications but defers to HIPAA and other general medical record privacy laws in the case of pharmacists and pharmacy technicians

10. Exceptions to Confidentiality • Required Disclosures • Abuse (child, elderly) • Injuries such as gunshot wounds • Reportable communicable diseases • Permitted Disclosures • 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 patient’s care

11. 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 person’s physician, lab director, etc. has not already done so.

12. Inappropriate Disclosure • You are working on a prescription for a patient who has an embarrassing bowel condition and the patient’s name sounds familiar. You realize that the patient is a co-worker’s ex-boyfriend. They didn’t part on good terms and so she laughs when you tell her about his plight.

13. Ask yourself… • Is sharing the PHI necessary for the patient’s treatment, billing or hospital operations, or has the patient authorized the disclosure? • Is sharing the PHI a required or permitted disclosure?

14. 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.

15. Handling Cousin Billy • Texas law allows a person’s 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

16. Accessing Records • When anyone not involved in a patient’s care, billing or hospital operations accesses the patient’s 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

17. 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 he’s taking.

18. Ask Yourself… • Do I need this information for the patient’s care? • Is this information I would legitimately have access to anyway? • Your minor child’s record • Your own record

19. 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 Princess’s 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.

20. The Princess’s Records • If you do not need access to a patient’s record for treatment, billing or hospital operations, it is inappropriate to access the patient’s record without the patient’s authorization. • This is true even if you want to access the record out of concern and not out of curiosity.