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MNAAP Newsletter

The Nitty Gritty of Providing Adolescent Confidential Services

DaveAugheyDave Aughey, MD, FAAP, Children’s Minnesota

Minnesota’s “Minor Consent” statute allows adolescents to receive confidential sexual health services. The statute does not mandate that clinicians need to provide confidential care. But if services are provided confidentially, the clinician is obligated to do everything possible to ensure 100 percent privacy for the patient.

This is an implied contract between the clinician and the patient and is consistent with “Do no harm.” When confidentiality is broken, not only is the patient’s trust violated, but a variety of harms may occur.

The clinician needs to be responsible for identifying when clinical encounters fall under the umbrella of being “confidential.” This is relatively easy when the entire encounter is for “confidential sexual care.” It becomes more challenging when the confidential care is a component of another visit, either an acute care or a preventive visit.

Documentation
Protecting privacy can be complex and challenging when one considers the nuances of care delivery. Documenting the care provided necessitates that the documentation itself needs to be sequestered in a separate and private area of the EMR that is not viewable on the patient’s portal or accessible if a parent requests records for that visit.
Also, confidential records should not be released by a general release of information signed by a parent unless the minor has specifically consented to the release.

Billing
Another issue which may expose a confidential encounter relates to the EOB for that visit. For patients covered by Medical Assistance, EOBs are suppressed by these plans for visits using billing codes related to confidential issues. However, for patients using private insurance, this is generally not the case and one should assume that the parent will receive an EOB. A mailed EOB is a very common reason for adolescents unintentionally having parents find out about a confidential encounter.

A similar issue is related to the handling of lab charges for an encounter. An itemized listing of lab charges may reveal a Chlamydia or HIV test having been done. Less obvious is when a parent directly calls the lab or billing office to inquire, “What is this lab charge for?” This has happened in our facility.

Follow up
Another component of confidential care delivery is the ability to contact an adolescent patient for follow up or lab results. Most EMRs or registration protocols do not collect telephone numbers of adolescents or have the capacity to do this. Most health care systems also do not permit sharing of results by directly texting or emailing patients due to HIPPA concerns.

Assess concern for privacy
When I am seeing a patient for sexual health issues, I ask the patient, “How important is it that this visit be private and that a parent doesn’t find out?”

If the patient is covered by Medical Assistance, my confidence is high about being able to provide complete confidentiality. Our clinics have EMR documentation options and policies for release of information practices that should ensure privacy. For these confidential encounters, there should be no systems issues that might compromise privacy. In the strictest interpretation of privacy for adolescents, no evidence should even exist that the patient was ever seen on the day of the clinic visit. However, one can only ensure privacy if “everyone along the way” does their job correctly, including all support staff.

If a patient has private insurance, I also ask, “How important is it that a parent doesn’t find out?” Compared to even 10 years ago, a suprising number of patients say, “It’s not that important as my mother already knows,” or, “I tell her everything.”

Refer, if necessary
However, if the response is that it’s very important to maintain complete privacy, I explain the various ways that a parent might find out. I then refer the patient to a clinic which has the ability to provide 100 percent confidentiality, which usually means a school-based clinic that offers this or a sliding scale community-based clinic. It is incumbent that clinicians know where to refer adolescent patients for confidential care that is local, affordable and reliable.

Sometimes doing the right thing means recognizing one’s limits and having contingencies for offsetting them. As someone who has seen the repercussions of having confidentiality broken, it is so important that we do this right.

Resources
AAP Committee on Adolescence

http://pediatrics.aappublications.org/collection/committee-adolescence

National Adolescent and Young Adult Health Information Center

http://nahic.ucsf.edu/

PATCH – Medical Records and Confidentiality
www.wipatch.org/uloads/2/0/5/4/20541726/patchworks_medrecordsandconfidentiality2017.pdf

 


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