Privacy and the Adolescent Patient

February 27, 2014

Navigating the complexities of privacy in the adolescent gyn patient can be tricky. Here, Deborah Ottenheimer, MD, a specialist in adolescent gynecology, shares her protocol for providing confidential medical care to teen patients.

Navigating the complexities of privacy in the adolescent gyn patient can be difficult and frustrating for clinicians as well as for the patient and her parent(s). As much as we would like to offer absolute privacy to our adolescent patients, our health care system isn’t set up to guarantee such an offering.

However, there are steps that we can take to better balance the needs and legal rights of our adolescent patients with those of her parents.

Clarify the Right to Privacy

Most of the teen patients I see come in for their first visit with a parent, usually their mother. After we have gone over the primary reason for the visit, I steer the conversation to the rights of the teen patient as related to privacy. My practice is in New York City, and my adolescent gyn patients are entitled to privacy with respect to STD screening and treatment, as well as to family planning services and evaluation/treatment after sexual assault.

I explain to both parent and patient that my primary relationship will be with the teen and that I will maintain that privacy except in very specific circumstances in which I feel that her life or health is in serious jeopardy. I also go over examples of health care decisions in which the parent will be involved, such as vaccinations, treatment of (nonsexual) medical conditions, and surgical consultations. Finally, I explain that, regardless of the circumstances, I will always insist on including my patient in any communication I may have with her parents.

About 50% of the parents/guardians are already aware of this need for privacy and are able to respect their child’s rights and independence. The other 50% go pale, grind their teeth, or otherwise show their displeasure with me. I always am quick to reassure parents that I am, in fact, on their side: I am interested in the safety and well being of their adolescent. I reassure them that I am not interested in keeping secrets and always encourage young patients to talk to their parents. I emphasize that my role is to provide a safe and confidential place for their child to come with questions or issues that they are facing.

Without fail, once our discussion is over and the parent has left the room, the adolescent slumps in her chair with relief and thanks me for protecting her privacy. We then can go on to talk openly about the issues that she is concerned about that she may not have been comfortable sharing with her parents.

Establish Trust

Once I am alone with my patient, I assess whether or not the “real” reason she is in my office is the same one she presented with her parent present. For example, is she really there to start the pill for her acne, or is she, in fact, sexually active and seeking contraception? This is also the time that issues of sexual abuse, depression or anxiety, or trouble in school may come out. Reassuring her that I will keep the discussion private is crucial to building trust and to ensuring that she is able to access the services she needs.

To paraphrase the observations of Abigail English, Director of the Center for Adolescent Health and the Law, “Findings from more than two decades of research has consistently documented that … privacy concerns can lead adolescents to delay seeking care or forgo care entirely and can affect their choice of provider, the candor of their responses to questions about sensitive topics, and their acceptance of specific types of care.” 1

Learn the Law

Learning the privacy and confidentiality laws in the state in which you practice is crucial to taking proper care of adolescent patients. There are three primary areas of privacy addressed by law: the ability of adolescents under the age of majority to consent to medical care without parental knowledge; the ability of parents to request copies of their adolescent’s medical records; and the issues presented by current billing practices of health insurance companies when the parent is the owner of the policy.

Every state has some provision that allows minors to seek medical care based either on the status of the minor or on the type of care they are seeking. 1 A minor can be classified as: emancipated; living apart from their parents; married; pregnant; and parents. Most states have statutes allowing these minors to consent to some or all of their health care. Every state has laws allowing all minors to consent to specific types of health care, including general care, family planning, STD/HIV care, drug/alcohol services, mental health services, and care for sexual assault. While many states allow minors to consent for family planning services, many also restrict access of minors to abortion services without parental consent. The Table from the Guttamacher Institute, from “An Overview of Minors’ Consent Law,” gives a brief overview of state laws regarding services and minor status.

 

Communicate the Confines of Reality

In principle, care consented to by a minor should also be protected by privacy laws. Unfortunately, a state-protected right to privacy does not always translate into real-world confidentiality.2,3 In some states, the parents can access medical records regardless of who (they or their teen) consented to the care. Transgression of privacy may also be accidental: for example, a busy practice may accidentally release records to parents that contain private aspects of a teen’s medical care. The expanding use of EMR’s may make this even more common, since there are often no safe-guards that allow this “restricted” content to be separated from the rest of the chart. Issues also arise when messages are left for the teen patient at home. It is crucial to be sure that you have the teen’s email and cell phone, rather than the parents’, on file.

Even when privacy in the office has been protected, a teen using her parents’ insurance may still have her confidentiality breached by the diagnosis/procedure codes on the explanation of benefits. Manipulating coding to hide the true nature of a teen’s visit is not advisable. In addition, laboratory billing is another source of privacy violation that is completely out of our control. It is important to always be honest with adolescent patients about the possibility that their insurance company billing may violate their privacy.

Navigating the complexities of privacy in the adolescent gyn patient can be difficult and frustrating. We need to balance the needs and legal rights of our patient with those of her parents. It is vital for anyone caring for adolescents to become familiar with the privacy laws of their state and to have a clear protocol for confidential medical care. In the end, however, if a teen patient insists that she needs absolute confidentiality, it is best to refer her to a local teen clinic, Planned Parenthood, Title X clinic, or other service that is able to provide free services unencumbered by parental involvement or third party billing.

References:

1. Sensitive Information in Medical Records: Protecting the Interests of Adolescents: Presented before the National Committee on Vital and Health Statistics Subcommittee on Privacy, Confidentiality, and Security (June 15, 2010) (testimony of Abigail English, JD, director of the center for adolescent health and the law. Available at: http://www.ncvhs.hhs.gov/100615p06.pdf. Accessed February 26, 2014.

2. Dailard C. New medical records privacy rule: the interface with teen access to confidential care. The Guttmacher Report on Public Policy. 2003;6(1). Available at: http://www.guttmacher.org/pubs/tgr/06/1/gr060106.html. Accessed February 26, 2014.

3. Gudeman R. Adolescent confidentiality and privacy under the Health Insurance Portability and Accountability Act. Youth Law News. July–September 2003. Available at: http://www.teenhealthlaw.org/fileadmin/teenhealth/teenhealthrights/yln/03_yln_3_gudeman_confidentiality.pdf. Accessed February 26, 2014.