Confidentiality and Privacy Breaches in a ... - Wiley Online Library

1142

ACADEMIC EMERGENCY MEDICINE

DEC 1997

VOL 4 / N O 12

Confidentiality and Privacy Breaches in a University Hospital Emergency Department Edu,ard J. Mlinek, MD, Jessica Pierce, PIiD

I

ABSTRACT . . . ... . .

..

,

..

..

.

....

.

..

.

...., . .

Objective: To determine the frequency of visual and auditory confidentiality and privacy breaches in a university ED. Methods: A prospective, observational study of medical personnel behavior was performed using participant and direct observation techniques. Observations were made in a university tertiary referral and trauma center emergency facility. Observers recorded auditory and visual confidentiality and privacy breaches in various patient care areas during I-hour periods. Information collected included patient name or room number, complainVdiagnosis, diagnostic tests, past medical history, and personal information. It was then determined whether a clear identification of the patient’s name or face and/or an association to his or her clinical course could be made. Results: All members of the health care team committed confidentiality and privacy breaches. Frequency of breaches was dependent on room location and design. Breaches in the triage/waiting area occurred for >53% of the patients. Breaches near the physicianhursing station ranged from 3 to 24 per hour and 1.5 to 3.4 per patient hour. Other inappropriate comments also were noted. One hundred consecutive patients and family members were interviewed at ED release, with only 3100 having noticed the status board, although neither could recall any specific details. Conclusion: Confidentiality and privacy breaches occur in a university ED by all members of the health care team. The ED architecture and floor plan affect patient confidentiality and privacy. Key words: confidentiality; ethics; emergency department; privacy. Acad. Emerg. Med. 1997; 4:1142- 1146.

I The right of privacy of an individual in relation to all

other people includes 3 aspects: 1) privacy as a physical sphere within which others may not intrude, 2 ) privacy as freedom of choice for important decisions, and 3) privacy as control over personal information.’ The principle of confidentiality is that a health care professional may not reveal to others the information provided by a patient without the patient’s consent.’ As is true for other specialties, emergency medicine (EM) has stated the importance of confidentiality to its practitioners. The American College of Emergency Physicians (ACEP) policy statement on patient confidentiality notes “ _. . all physicians have an important ethical and

From rlre University of Nebraska Medical Centel; Omaha, NE, Department of Surgeryn Section of Emergency Medicine (EJM), and D e partment of Prevenrive and Societal Medicine (JP). Received: F e b r u ay 25. 1997; revision received: June 11. 1997: a c cepted: .June 2 1 , 1997: updated: July 8. 1997.

legal duty to guard and respect the confidential nature of the personal information conveyed during the patientphysician encounter. . . .” However, the emergency physician and patient confidentiality guidelines as prepared and reviewed by members of ACEP’s Ethics Committee do not specifically address confidentiality during patient care.3.4 Prior publications on the issue of confidentiality in EM generally address confidentiality breaches as they relate to various clinical situations, e.g., employee health, communicable diseases, and drug te~ting.’.~.‘ Few articles have examined inappropriate comments made by hospital employees while i n a public space (the hospital elevator)’ or addressed confidentiality in the ED.‘ Confidentiality, particularly in policy form, also relates to the protection of specific verbal or written information. Our study sought evidence for confidentiality and privacy breaches in the ED. We also discuss how ED architecture and floor plan can affect these issues.

Prior presenration: SAEM annual meeting, Washington, DC. May 1997.

I METHODS

Address for correspondence and reprints: Edwnrd J. Mlinek. M D , c/o Section of Emergency Medicine, Department of S u r g e y 600 South 4?nd Street. Box 981 150, Onialin. N E 68198-1150. Fax: 402-559-9659: e-mail: em linek @ mail.unmc.edrr

Study Design: We performed a prospective, observational study of ED personnel and patient information displays using participant and direct observation techniques.’

1143

Confidentiality and Privacy Breaches, Mlinek, Pierce

The study was given an exempt status by the University of Nebraska Medical Center Institutional Review Board.

Study Site: The study was performed in a university hospital ED providing tertiary referral and trauma center service with approximately 22,000 patient visits per year. Observers: The authors of this study, full-time faculty members at the University of Nebraska Medical Center, served as observers. One is an attending physician in the ED and the other a member of the department of preventive and societal medicine. The observers did not receive any specific training because their educational backgrounds and patient care experiences were considered sufficient to record the desired information. Measurements: Observers recorded field notes describing auditory and visual information obtained during 1hour observation periods. Observations were recorded for patients who were present in the ED during the observation periods in 2 main areas: In the triage/waiting area, the observers sat in chairs where patients or family members would sit. In the ED patient care area, they sat in various empty patient rooms, which varied both in location within the department and in structural design. The auditory information recorded included but was not limited to a patient’s name, face or room number, chief complaint, diagnosis, past medical history, or other significant personal information, e.g., insurance status, address, and telephone number. Visual information was recorded as it was observed, e.g., a patient’s face. The observation periods continued until a theoretical point of saturation was achieved.8 Field notes were reviewed to determine whether confidentiality or privacy breaches occurred. A breach was considered to occur when a patient’s name was heard in combination with a diagnosis, test, or significant personal information, or when such information could be associated with a patient’s face. Upon ED release, patients and accompanying family members or visitors were asked: 1) whether they knew how we kept track of patients in the department. 2) whether they had noticed our status board, and 3) whether they could recall any details from the status board.

I RESULTS . .. . .. .

. . .

. .

.. . .

..

. ..... .....

.

. .

Waiting Room/Triage Area: A total of 32 patients checked in during 6 1-hour observation periods. The patient’s name was overheard for 81% (26/32). The diagnosis or presenting complaint was obtained for 56% (18/ 32). The patient’s name and diagnosis or presenting complaint were obtained for 53% (17/32). Insurance status was noted for 72% (23/32) at the time the patient was being checked into the department. Occasionally, patients

were associated with miscellaneous comments including their address, home telephone number and social security nu m ber.

ED: A total of 18 1-hour observation periods were completed. Visual and auditory breaches near the physician/ nursing work area occurred between 3 and 24 per hour, or between 1.5 and 3.4 per “patient hour” (based on the number of patients in the department for each 1-hour observation period). During 1 observation period near the work area, 5 of the 7 patients in the department were identified by name, diagnosis, and tests ordered. All members of the health care team, attending physicians, residents, medical students, nurses, paramedics, clerks, volunteers, and other ancillary personnel, committed breaches, although identification of the person committing the breach could not routinely be identified. In patient care areas with “curtain walls,” almost everything could be heard by an observer in the next room. Similarly, rooms separated by glass partitions provided no limitations in the information overheard. Rooms with solid walls and doors did not allow for any breaches in confidentiality or privacy. Visual breaches were recorded when significant information about a patient could be gathered by observing, e.g., when a curtain was left open, leaving a patient’s body uncovered and within easy view. These occurred when the front curtain of the patient room was not kept closed. Observations included a patient being sutured, with his face, legs, and buttocks readily in view; a patient in a wheelchair with a bloody head bandage and his face showing; a patient wheeled by with the announcement “head CT to rule out tumor.” Other Inappropriate or Unprofessional Comments: During observation periods, a number of inappropriate or unprofessional comments also were made and easily overheard: “Dr. ‘X’ always sends her patients in . . . she can never figure things out”; “Mr. ‘Y’ is a pain in the ass”; “Piss ‘Y’ off so he’ll leave AMA”; “ ‘Z’ hospital sucks”; “Your lady in room 4 is lying, she has had sex.” While not violating patient confidentiality, these comments might raise questions in the minds of patients or family members about the quality of care and professional desire to provide quality care.

ED Release Interviews: Finally. of those patients and family members interviewed at ED release, only 2 of 100 interviewees had noticed the status board, and neither of the 2 could recall any specific details.

I DISCUSSION Participant observation has its roots i n social and cultural anthropology and has been a useful method i n medical

~~

1144


anthropology for researchers in primary care settings. Obtaining an understanding of how any social institution or organization works, including a hospital, is best achieved through participant observation.’ “It involves getting close to people and making them feel comfortable enough with your presence so that you can observe and record information about their lives” as they go about their daily business; it also requires the realization and acceptance “. . . that it involves a certain amount of deception and impression management. . . .”’ The issue that the observers were known to the ED staff is entirely within the accepted descriptions of this technique. Participant observation reduces the problem of reactivity, i.e., people changing their behavior when they know they are being studied. Presumably, lower reactivity means higher validity of data.

1. We All Know “the Rules”: Within the extensive confidentiality literature, there is almost complete consensus on the following points. First, commentators agree that privacy, as such, is valuable. We value privacy because it signals respect for human dignity. In honoring privacy, we also honor human dignity and individual autonomy. Confidentiality is a rule that all health professionals are obligated to follow except under carefully prescribed circumstances: when a breach is required by law (reporting communicable diseases and crime-related injuries) or when a breach is necessary to protect an identifiable third person who is at risk. The ACEP policy statement acknowledges, however, that “. . . there are circumstances in which no societal consensus exists about phether to disclose patient information.” The terms “confidentiality” and “privacy” are sometimes used interchangeably in the literature, yet some distinction can be made between them. Confidentiality refers specifically to the handling of information that has been shared between doctor and patient. There is broad consensus that the duty of confidentiality is based on 1) respect for privacy, 2) the relationship of trust between physician and patient, 3) the assumption that a general respect for confidentiality is essential to good patient care because when it is present patients will disclose more complete information. We were not able to distinguish between confidentiality and privacy breaches from the majority of our data. In considering their closely interwoven nature, we chose to combine them in our reporting of the overall frequency of breaches. However, whenever possible, the distinction is discussed. In the waitinghiage area, breaches of privacy occurred as the patient was interviewed in an area that did not provide auditory privacy. Occasional breaches in confidentiality also occurred when clerks called the physician on-call for certain health care plans seeking approval for the patient to be seen and evaluated in our ED; during these telephone calls, the patient’s name, presenting com-

’

DEC 1997

VOL 4/NO 12

plaint, and insurance status were stated and readily heard by those in the waiting area. One study reported that 99% of the responding physicians and nurses either agreed or strongly agreed that privacy is a right, that confidentiality is important, and that maintaining confidentiality is part of the individual health care professional’s responsibility.’ Such an overwhelming commitment to privacy and confidentiality seems oddly out of place in relation to our observations. It is possible that the observers in our study would detect more breaches due to their specific intentions and educational backgrounds. However, the important issue is that breaches of confidentiality and privacy do readily occur. Potentially sensitive patient information is readily available to anyone who cares to take notice. N o special training is required to recognize a patient’s name, address, insurance status, chief complaint, or most diagnoses. We should also recognize that the general public is becoming more knowledgeable medically. We should not assume that they will not understand medical terms or jargon used for the sake of not being more conscious of confidentiality or privacy issues. We are currently in the process of investigating patients’ confidentiality and privacy expectations and experiences in our ED. Our present study questioned patients, family members, and visitors about their experiences with the ED status board only. With such an abundance of material written about confidentiality, with carefully manufactured hospital policies, with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines, and semper discretis signs posted all around the hospital, why are confidentiality and privacy still so neglected in practice?

2. Why Don’t the Rules Work and What Can We Do Differently? Perhaps the ED is uniquely unsuited to privacy and confidentiality. The pace, urgency of care, and overall environment i n the ED may be at odds with these very issues. In the ED, we place a high value on efficiency and speed of care. Perhaps these values cannot work alongside privacy, so that efforts to secure a private environment in the ED are senseless. On the other hand, it could be that the crisis mentality and the sort of “slow hurry” that characterizes work in an ED are not fundamentally at odds with privacy, but simply lend themselves to confidentiality breaches and loss of privacy for patients. Protecting privacy may require only increased vigilance. It might also require dramatic changes in how ED care is organized and managed. Assuming that ED care is compatible with confidentiality and privacy, what factors might affect our ability to protect these values? One of the factors in our ED was the spatial layout. In our ED, patients must check in with a clerk or a nurse several feet from where other patients or visitors may be sitting. This is despite JCAHO patient rights noting that

1145

Confidentiality and Privacy Breaches, Mlinek, Pierce

“patients are to be interviewed out of the hearing range of other patients in the waiting room at outpatient sites. l o Presumably, confidentiality and privacy were not the main considerations in a recent remodeling of our waiting area, completed just prior to the onset of our study. A possible solution to provide a more audibly secure area include changing the structural design during another remodeling of the area. The addition of background music or the use of physical barriers to limit noise transmission may prove equally beneficial in enhancing auditory privacy. In regard to the patient care area of the ED, rooms with walls and doors provided the most private and confidential environment. Observers outside these rooms could hear nothing from inside the room, provided the door was closed. Observers inside these rooms could not hear or see anything, maintaining their and other patients’ privacy. The curtained rooms offered almost no protection in terms of sound. These “curtain walls” allow violations of patient privacy during patient interviews. These rooms also allow for breaches in confidentiality if discussions about other patients occur in proximity to these “walls.” Visually, curtains offered more privacy than glass; however, most of the time curtains were left open when patients were i n the rooms. The glass walls leave on open visual field and do not provide auditory privacy between adjacent rooms. Not only was the visual field completely open, but because the glass doors were routinely left ajar almost everything happening outside the room could be heard. Rooms located nearest the physiciadnurse work areas typically allowed the most breaches of confidentiality. Patients in these rooms would be both most likely to hear about other patients in the ED, and most likely to have the least privacy of their own. Many discussions about patients occur while staff members stand at the main desk. If patients in rooms near this area were inclined to listen, they would know a great deal about other patients being seen in the ED. Limiting staff discussions of patients near patient rooms would obviously decrease confidentiality breaches. In our department, e.g., the work desk would ideally be set back a little more from patient care areas, and the space behind the desk made more suitable for studentl resident presentations. Reports over the telephone to admitting services and shift sign-outs by physicians and nurses should be done in a more audibly secure area. Perhaps even better would be to have all such activities take place in an enclosed area, away from the main work space and patient care areas. Many of the breaches we recorded occurred simply in the course of daily work in the ED. Staff members talk to each other through curtains and across the patient care area of the department in normal or even raised voices. Patient information is handed back and forth in these venues. If such communications were considered by some to

be vital, then a compromise of patient confidentiality might be justified. However, we believe the verbal use of patients’ names should be limited to audibly secure areas and not spoken loudly across the department or through curtains of patient rooms. A certain amount of information that seemed important in terms of patient privacy d i d not fall under our definition of ”breach,” e.g., the mostly naked patient left in open view. Closing curtains and doors could potentially eliminate most of the visual breaches, and perhaps some of the auditory ones as well. Even if a patient’s clinical condition warrants constant direct observation, e.g., patients with potential for clinical deterioration, the curtain could be closed for short periods when other patients are being transported by the room or when the patient is being cared for by members of the health care team. In order to provide optimal care, patients who have medical conditions that warrant continuous direct close observation should not be placed in rooms in which they cannot be directly observed even if some compromise of their privacy occurs. Rooms with solid walls and doors may to some degree isolate patients as well as members of the health care team caring for them. These rooms may to some extent limit medical staff safety through the very means taken to ensure patient confidentiality and privacy. Care must be taken to avoid placing potentially dangerous patients in these sound and visually protected rooms. ED personnel must also recognize potentially dangerous situations regardless of the structural design of the patient’s room and take appropriate steps to protect the patient and themselves. All of our rooms are also equipped with call buttons for when any patient needs immediate assistance. These steps may help to ensure optimal patient care while maintaining a confidential environment. Still, certain practices that seem an affront to patient privacy are perhaps unavoidable. For example, all patients who receive x-rays are transported via wheelchair through the ED, through the hospital corridors, into elevators, and down to diagnostic imaging. Some patients may feel uncomfortable being wheeled through a crowded hospital in a hospital gown, but it is difficult to imagine an alternative practice without thorough redesign of the hospital. The ED status board h a s previously been identified as a potential threat to patient confidentiality.” The JCAHO notes that in the ED . . triage boards can’t contain any diagnostic information but can list the patient’s first initial, last name, and very generally where they are going [e.g., radiology]. . . .” l 2 It is a common perception by ED practitioners that the status board does benefit patient flow and efficiency of care. However, the board may be strategically placed so that it is highly visible to staff while somewhat obscured from general view. Also, methods of documentation might be possible that balance patient confidentiality with ease o f use. In our institution we are attempting to use relatively self-explanatory colors to rep‘&.

1146


resent the patient’s general chief complaint, e.g., red: cardiovascular, blue: pulmonary, brown: gastrointestinal, yellow: genitourinary, gray: neurologic. Finally, continuing education of health care workers about how to protect patient confidentiality and privacy may be important.

3. Are Confidentiality and Privacy Outmoded Values? We wail about the loss of privacy and confidentiality in hospitals, yet it seems quite obvious that these systems for managing human health are not designed to be private, e.g., semiprivate rooms and curtains rather than solid walls. Perhaps economic efficiency and growth are the primary motivation i n design and are really at odds with patient privacy. We should rethink, and then carefully state, which of these values is more important within the health care industry.

I LIMITATIONS AND FUTURE QUESTIONS ................................................ The results of our study are truly applicable only to our institution due to its architecture, structural design, and spatial layout of the patient care areas, and the clinical practices of members of the health care team. The need for medical student and resident presentations and subsequent discussions in regard to patient management issues may increase the likelihood of some of the confidentiality breaches. The breaches in these instances should not occur in those EDs without student or resident training programs. However, in our opinion and experiences, confidentiality and privacy breaches occur to some extent in most ED settings by members of the ED staff, ancillary personnel, or consulting services. In addition, we did not assess interobserver reliability regarding the observations made, although our empiric definitions of confidentiality and privacy breaches allowed little variance in interpretation. Given the limited patient awareness of the patient status board, it is unclear how often the breaches that we observed are recognized by patients. Future investigations should address these issues.

I CONCLUSION . . . . . . . . . . . . . . . .

DEC 1997

VOL 4 / N O 12

. . . . . . . . . . . . . . . . . . .

Confidentiality and privacy breaches are a routine occurrence in the ED at our hospital. All members of the health care team were observed to violate patient confidentiality during the normal process of patient care. One factor affecting patient confidentiality and privacy is the physical layout of the ED, particularly the placement of the checkin desk i n relation to the patient waiting area. Proximity of patient care areas to the workstation and “curtain walls” around patient rooms also facilitate breaches.

I REFERENCES 1. Privacy and confidentiality. In: Iserson KV, Sanders AB, Mathieu D. Ethics in Emergency Medicine, Second Edition. Tucson, AZ: Galen Press, 1995. pp 153-85, 320, 386, 416. 2. American College of Emergency Physicians. Patient confidentiality. Ann Emerg Med. 1994; 24:1209. 3. Larkin GL, Moskop J, Sanders A, Derse A. The emergency physician and patient confidentiality: a review. Ann Emerg Med. 1994; 24: 1161 -7. 4. Sanders AB, Derse AR, Knopp R , et al. American College of Emergency Physicians: Physicians’ Ethics Manual. Ann Emerg Med. 1991; 20: 1 153-62. 5. Ubel PA, Zell MM, Miller DJ, et al. Elevator talk: observational study of inappropriate comments in a public space. Am J Med. 1995; 99:190-4. 6. Mortlock T. Maintaining patient confidentiality i n A & E. N u n Times. 1994; 90(34):42-3. 7. Bernard HR. Participant observation. In: Bernard HR (ed). Research Methods in Anthropology. Newbury Park, CA: Sage Publications, 1994, pp 137-64. 8. Strauss A, Corbin J . Theoretical sampling. In: Strauss A, Corbin J (eds). Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage Publications, 1990, p 188. 9. Grady C, Jacob J, Romano C. Confidentiality: a survey in a research hospital. J Clin Ethics. 1991; 1:25-30. 10. Anonymous. Comprehensive Accreditation Manual for Hospitals. Chicago, IL: Joint Commission on Accreditation of Healthcare Organizations, 1991, p 89 (RI.1.3.2). 11. Mines D. The ED status board as a threat to patient confidentiality. Ann Emerg Med. 1995; 25:855-6. 12. MacDonald I (ed). Briefings on JCAHO. Med Answers. 1996; 7(3):

16.