[Congressional Record (Bound Edition), Volume 152 (2006), Part 5]
[Extensions of Remarks]
[Pages 7154-7155]
[From the U.S. Government Publishing Office, www.gpo.gov]



[[Page 7154]]

                          EXTENSIONS OF REMARKS

       NATIONAL POLICY CONCERNING PRIVACY OF HEALTH CARE RECORDS

                                 ______
                                 

                          HON. TED STRICKLAND

                                of Ohio

                    in the house of representatives

                         Wednesday, May 3, 2006

  Mr. STRICKLAND. Mr. Speaker, on behalf of the National Academies of 
Practice I would like to submit the National Policy Concerning Privacy 
of Health Care Records Paper to the Congressional Record.

       National Policy Concerning Privacy of Health Care Records


                                Summary

       Confidentiality--the understanding that information given 
     in confidence will be held in confidence--has characterized 
     the patient-practitioner relationship for the last 2400 years 
     or more. It has been an essential component of the 
     professional's promise to be a conscientious fiduciary, a 
     promise that has been the cornerstone of patient trust in the 
     health care system.
       Privacy--the right of the individual ``to be left alone,'' 
     a liberty of personal autonomy that the Supreme Court has 
     held to be protected by the 14th Amendment--has been emerging 
     over the last several decades as a salient issue in health 
     care. This emergence is driven by technological changes that 
     have radically altered the ability of confidentiality pledges 
     alone to assure the security of sensitive personal 
     information. Privacy is related to confidentiality but has 
     differing implications that need to be understood.
       An effective health care system requires sound public 
     policy that sensitively addresses privacy and confidentiality 
     issues in ways that do not jeopardize the crucial patient-
     professional relationship and do not impair the 
     practitioner's ability to justify the trust of his/her 
     patients.
       Introduction: This paper is a brief description of the 
     issues involved in health care confidentiality and in 
     statutory regulation of patient privacy rights. It suggests 
     the direction that national policy should take in addressing 
     these issues. It reflects the perspective of the National 
     Academies of Practice (NAP), a multidisciplinary body of 
     distinguished health care practitioners that was founded to 
     distill the wisdom of the practice community into functional 
     national health policy.
       Confidentiality: Confidentiality is the assurance that 
     information received in confidence will be held in 
     confidence. As part of their ethical commitment, 
     professionals have promised confidentiality of patient 
     information from as long ago as approximately 400 BC, with 
     the introduction of the Hippocratic Oath: ``All that may come 
     to my knowledge in the exercise of my profes-
     sion . . ., which ought not to be spread abroad, I will keep 
     secret and will never reveal.'' A similar confidentiality 
     promise has been incorporated into almost every ethics code 
     of almost every health care profession since that time. 
     Trust, based in part on assurance of confidentiality, is 
     necessary to achieve open communication and cooperation. 
     Without such trust, professional effectiveness is severely 
     limited or impossible. The National Consumer Health Privacy 
     Survey of 2005 (California HealthCare Foundation) suggests 
     that this trust is severely stressed in our modern health 
     care system.
       Privacy: Privacy, in the words of Justice Louis Brandeis in 
     1890, is the ``right to be left alone.'' This right has been 
     held to be supported by the 14th Amendment, and partially 
     supported by the 1st, 4th, and 5th Amendments. In varying 
     degrees, the right has been extended to certain personal 
     records and other information; however, case law and judicial 
     holding about the right to privacy of personal information is 
     still in flux. The November 2, 2005 ruling on No. 04-2550 in 
     the United States Court of Appeals for the Third Circuit, 
     Citizens for Health v. Leavitt, suggests that such right may 
     depend more on individual statutes than on constitutional 
     protection.
       Privacy was not a traditional consideration in health care, 
     but has become one. The patient does not want to be ``left 
     alone'' in the treatment relationship, but does want his or 
     her health information to be held in confidence. 
     Traditionally, when only the professional had access to the 
     record, usually a hand-written notation in his or her private 
     file, privacy of the record itself was automatic so long as 
     confidentiality was maintained. Today, good health care 
     requires that the professional's findings be entered into a 
     permanent health care record that is available to multiple 
     other parties. When that happens, the professional loses 
     control of the information, and only protection of the record 
     itself can assure professional confidentiality. That 
     protection is directly dependent on privacy policies or laws 
     that fall under statutory rather than professional control.
       Adjudication of privacy rights under law, especially the 
     extension of those rights to health record information, did 
     not have its origin in health care concerns. herefore, people 
     writing privacy policy tend to be unfamiliar with the 
     tradition of health care and confidentiality, just as health 
     care providers, steeped in the tradition of confidentiality 
     as an ethical commitment, tend to be uninformed about the 
     nuances of privacy law. The hazard is great that health care 
     practitioners, with the wisdom of the ages behind them in 
     building necessary patient trust, will be ignored in the 
     development of privacy law and that those who develop privacy 
     policy will be insensitive to the critical nature of the 
     patient-practitioner relationship. At risk is the 
     functionality of health care delivery, one of the most 
     humanely important and economically significant enterprises 
     in the country.
       Cultural Shift from Confidentiality as Sole Protector of 
     Privacy: The Joint Commission on Accreditation of Healthcare 
     Organizations (JCAHO) and other groups require accredited 
     facilities to have in place patient's rights regulations that 
     protect sensitive health information. As noted, the safety of 
     such records can no longer depend on confidentiality 
     agreements alone. Privacy of the health care record itself 
     has to be assured. Extensive national policy positions have 
     recently been established to address the privacy issue. The 
     most notable is the Health Insurance Portability and 
     Accountability Act (HIPAA), which laudably adds many 
     necessary patient protections. Health care professionals 
     nevertheless find HIP AA to be both ineffective and 
     burdensome in certain key respects. Future refinements are 
     clearly needed. Understanding the shift from exclusive 
     reliance on confidentiality to the need for privacy laws can 
     point toward effective solutions. Four trends warrant 
     highlighting.
       Numerous health care professionals, third party payers, 
     employers, and support personnel are routinely involved in 
     today's health care system. The health care record has become 
     the medium of communication among these involved groups. The 
     health care professional can neither functionally withhold 
     sensitive information from the record nor control the use of 
     that information by others. The old promise of 
     confidentiality is therefore no longer adequate protection of 
     the sensitive information.
       Technology has greatly increased the amount of sensitive 
     information that directly enters the record, information that 
     is not directly under the practitioner's control. These data 
     include X-rays, blood chemistries, and numerous other 
     laboratory or technologist-based findings. At the same time, 
     the need for these laboratory personnel and technologists, as 
     well as insurers, consultants, and others, to have access to 
     health care information increases. All of these developments 
     magnify the importance of controlling the health care record 
     itself and its use by everyone with access to it.
       The growing complexity of the health care system places 
     increasing demands on the health care record. In response, 
     the information age is replacing traditional multiple written 
     records with a single electronically encoded one that can be 
     accessed by almost any properly prepared person almost 
     anywhere on earth. This shift to an agglomerated record in 
     electronic format greatly magnifies the utility of the record 
     as an aide to effective health care. At the same time, it 
     creates a nightmare for control of privacy of the information 
     it contains. Not only are confidentiality pledges inadequate 
     but so also are privacy laws that cannot prevent hacking and 
     other forms of electronic information theft.
       The primary ingredient of effective health care over the 
     last 2400 years or so has been the commitment of health care 
     professionals to be conscientious fiduciaries. That continues 
     to be the primary ingredient, but one that is being 
     increasingly obfuscated by the shift from guild control to 
     legal control of health care practice. As already noted, laws 
     are necessary to implement privacy rights. Similarly, legally 
     enforced licensing laws have replaced guild control of code 
     of conduct issues, and the growing complexity of the health 
     care system has interfaced health care with the legal system 
     as never before. The result has been a tendency to raise both 
     public and regulatory expectation that legal mandate can 
     guarantee professional integrity. In fact, laws can 
     supplement but cannot guarantee or replace professional 
     integrity,

[[Page 7155]]

     which is as critical today for effective health care as it 
     ever was. How far this muddying of the critical importance of 
     the professional relationship will go remains to be seen. In 
     the mean time, it creates a pressure for the professional to 
     shift away from ``caring'' practice to ``safe'' practice and 
     for the patient to shift away from a ``trusting'' attitude to 
     a ``litigious'' attitude. Both of these trends are often at 
     the expense of effectiveness of treatment and economy of 
     service delivery. The shift toward legal regulation is 
     inevitable, so the sensitivity with which policies and laws 
     are drafted is absolutely critical for the future health of 
     the nation.
       The foregoing are dramatic changes in long-accepted 
     traditions. Privacy of the health care record, legally 
     regulated, is the visible ``new kid on the block.'' Unlike 
     professional confidentiality, it has little ``wisdom of 
     history'' behind it. Not surprisingly, there is a tendency to 
     address privacy by tactics that might work for 
     confidentiality but do not work for privacy, by placing heavy 
     penalties on professional breaches. This is ineffective when 
     little attention is given to the leaky-sieve aspects of the 
     health care record system itself. In fact, it can be severely 
     counter-productive if it poisons the traditional trusting 
     relationship between patient and professional. The urgent 
     need is for highly sensitive and highly enlightened health 
     care policy that preserves the wisdom of the past.
       Tentative Answers to Complex Questions: Five questions 
     arise in the context of the new privacy era in health care.
       1. How extensive should the health care record be? The 
     health care record will, and should, become increasingly 
     complex and extensive. Information technology allows the 
     retention and utilization of vast quantities of information. 
     The future health care record will almost certainly be in 
     electronic form. With electronic data manipulation 
     techniques, even an extensive record can be efficiently 
     sorted to allow quick decisions about immunizations, 
     allergies, past responses to specific treatment approaches, 
     drug interaction risks, excessive or inappropriate drug use, 
     and similar questions of care. Aggregated data across a given 
     problem or disease spectrum could identify both promising and 
     ineffective treatment approaches. The potential gain from 
     having such records is impressive indeed, and the technology 
     for collecting, preserving, and utilizing them is already 
     largely in place.
       2. Who should have access to what information? Portions of 
     the health care record should be accessible by every health 
     care practitioner with whom each client will potentially 
     interact. Other portions should be accessible by insurers, 
     managed care officials, and similar non-health-care personnel 
     who have a direct and necessary ``need to know.'' Portions 
     should be available for malpractice monitoring and similar 
     purposes. Portions should be available to research programs, 
     perhaps stripped of data identifying the individual source. 
     The number of people who should have legitimate access, in 
     the interest of improving the health of both our individual 
     citizens and the nation itself, will inevitably grow.
       3. How can access be made easy on a ``need to know'' basis? 
     In this electronic age, partitioning the record for limited 
     access is technologically easy. For example, a school nurse 
     needing to certify an immunization record neither needs nor 
     wants to sort through the entire record. An electronic 
     summary of immunizations can be programmed into the record 
     and be made immediately available to a coded request by a 
     ``school health worker.'' Similarly, current health status 
     and current proposed or completed treatments can be 
     electronically isolated for benefit of reimbursement or 
     managed care assessments without exposure of the entire 
     chart. The mental health record can be sequestered, with 
     access limited to those with legitimate interest in that 
     area. In general easy electronic access to appropriate data 
     can be designed into the system, provided inappropriate 
     policies do not frustrate legitimate access in the name of 
     security.
       4. How can inappropriate access be prevented? Any effective 
     solution requires that the electronic record itself be 
     designed from the beginning to incorporate essentially fail-
     proof security features. In the past, ``loose lips'' were the 
     primary problem, people with legitimate information 
     intentionally or unintentionally leaking that information. 
     Control of people was the primary solution. Within the health 
     care professions, lapse of confidentiality has long been 
     addressed by guild ethics and by licensing laws that regulate 
     the actions of the professionals. Outside of the health care 
     professions, especially in the economic sector, abuse of 
     confidentiality still needs to be addressed more effectively.
       Although important, loose lips are not the primary problem. 
     They usually endanger only one person at a time, rather than 
     thousands whose data may be accessible in the electronic 
     record. Limiting access to the electronic record to those 
     with a legitimate need to know is the most significant key to 
     guaranteeing privacy. Electronic data can be hacked, copied, 
     transported, collected, sold, and otherwise manipulated in 
     ways that are difficult to detect by people who are hard to 
     identify. Passwords and other access codes, encryption, and 
     the like may be essential, but they are not enough. The 
     Internet, the primary platform for current electronic data 
     portability, has not yet achieved the levels of security that 
     are necessary.
       A workable system might involve a completely separate 
     health information network operating out of a centralized 
     data bank and accessible only through authorized terminals. 
     Security might involve requiring bioelectronic screening for 
     palm prints, iris patterns, voice prints, or the like prior 
     to system access. Electronic ``footprints,'' or audit trails, 
     could preserve a record of all data accessed and for what 
     purposes. An alarm system could alert a central information-
     monitoring group when an unauthorized access was attempted or 
     when an unusual pattern of access was detected. Such steps 
     would make unwarranted penetration of the system rare, access 
     to the system by authorized persons easy, and apprehension of 
     violators probable.
       5. Who should control the privacy information? Privacy 
     rights should guarantee that health care information is held 
     confidential within the health care system, except as the 
     patient explicitly opts out of the privacy agreement. It is 
     the patient's knowledge that his or her own sensitive 
     information will be used only for health care purposes that 
     assures the trust necessary for effective cooperation. 
     Circulation of the information within the legitimate health 
     care system is necessary and functional, but circulation 
     outside of that system, without explicit and uncoerced 
     patient consent, should be taboo. Public knowledge of 
     personal health problems can be severely damaging. One only 
     has to recall Eagleton's vice-presidential nomination.
       A few legally mandated requirements, such as the duty to 
     protect or the duty to alert authorities of abuse of helpless 
     patients, currently require exceptions to confidentiality. 
     Perhaps other exceptions are warranted, but professional 
     experience suggests that they should be rare and very 
     carefully crafted. We suggest that they should be limited to 
     those circumstances that pose an explicit future threat to 
     others or an abuse against which a patient is not capable of 
     protecting himself/herself.
       While a patient may voluntarily choose to waive some 
     privacy rights, perhaps in exchange for convenience or other 
     benefits, waivers that are determined by law as part of 
     health care policy, as in certain sections of HIPAA, are 
     often more disclosure notices than they are matters of 
     voluntary consent. Without true voluntary consent, there is 
     no choice and no trust. These complexities reflect the early 
     growing pains of privacy law and can have serious unintended 
     consequences.
       It is in these areas of developing health care policy and 
     related privacy law that health care practitioners can make 
     some of their most important policy contributions. The danger 
     is that others who determine such policies may either fail to 
     understand or simply disregard the practitioner perspective, 
     at great harm to the nation's health.
       Conclusions: Practitioner work is anchored on two premises 
     that have stood the test of time: patient trust, which is 
     necessary for essential communication, and the guarantee of 
     confidentiality of information, which requires that the 
     health care record be used exclusively for health care 
     purposes. The National Academies of Practice recommends that 
     information in the health care record should be exclusively 
     available for health care purposes and that the record should 
     be protected from access for any other use.
       Maintaining privacy with an ever expanding and easily 
     accessible electronic health care record, in an ever more 
     complex health care delivery system, requires new approaches. 
     These approaches must be integrated into the record keeping 
     and service delivery systems themselves, through 
     technological safeguards. Health care practitioners cannot 
     control the privacy of the health record and do not control 
     privacy policy, but our long experience with confidentiality 
     issues and our pragmatic wisdom concerning the treatment 
     process offer understanding that should be an essential part 
     of policy development.
       Some present trends in national privacy policy are 
     threatening the integrity of the practitioner/patient 
     relationship. A sensitive and sophisticated privacy policy 
     for health care records that does not jeopardize the 
     necessary trust of the patient is critical to assure the 
     effectiveness of health service delivery. Health care 
     professionals that represent the wisdom of the 
     multidisciplinary practitioner community are an indispensable 
     resource for such policy development. Failure to incorporate 
     them, visibly and functionally, into the policy making 
     process risks jeopardizing the millennia-long practitioner 
     tradition of establishing consumer trust on which the 
     effectiveness of health care depends.

                          ____________________