To optimize care for minor adolescent patients, pediatric providers need to create practice policies addressing the confidential needs of these minors and develop work flows to accommodate those policies. Additionally, pediatricians need to integrate confidentiality for adolescent patients into the practice’s electronic health record (EHR) and patient portal if one is utilized. In this article, we present suggestions for achieving these goals.
Nuances of adolescent medicine
Adolescence represents a period of rapid change wherein patients seek advice from friends, family, and physicians on topics such as sexuality, drug use, and mental health. Unfortunately, adolescents have the lowest rate of primary care usage of any age group cared for by pediatricians. One study showed that one-third of adolescents had no preventive care visits from ages 13 to 17 years while another 40% had a single visit.1 Issues that are difficult for teenagers to talk about include violence, depression, anxiety, suicide, drug use, and sexuality.2
Adolescents are more likely to see a provider if they are told the information will be kept confidential. These assurances result in patients more likely to return for follow-up visits.3-5 There are many barriers to confidential care for adolescents. These include the conspicuous lack of knowledge regarding minor consent laws among pediatric providers, and the ability to maintain confidentiality for adolescents with commercial insurance coverage and within shared medical records.6,7
It should be noted that although pediatricians strive to respect the confidentiality of our patients, we are at times obligated to disclose our patients’ healthcare information without their support to reduce risk or prevent harm. Examples include when there is suspicion of sexual or physical abuse or admission of homicidal or suicidal thoughts.
The road best taken
Medical practices are able to set specific policies regarding confidentiality for adolescent patients, as long as they do not violate state or federal laws. By doing so within professional guidelines, pediatricians can improve the care provided to their adolescent patients, as well as dramatically improve access to care. The American Academy of Pediatrics (AAP) recommends that adolescent visits include “private time” with providers to discuss sensitive issues and review confidential health screens. It has been shown that in most practices, however, only 50% of visits incorporate some private time. In adolescent clinics staffed by pediatricians with fellowship training in adolescent medicine, inclusion of private time is nearly 100%.7
The Children’s Hospital New Orleans, Louisiana, has an adolescent patient policy that facilitates adolescent visits by including the following guidelines:
· Adolescents have the right to speak with providers alone without parents or guardians in the room. Adolescents are encouraged to share or include discussions with parents or guardians when able.
· Adolescents have the right to the confidentiality of their clinical records, as well as the right to access their own health information.
· Under Louisiana state law, minors are allowed to give consent to medical or surgical care without permission from a parent or legal guardian. This care is extended to patients aged 13 years and older at the Children’s Hospital New Orleans.
· Adolescents have the right to have options for care explained to them and to participate in their plan of care.
To implement the above policy, the Adolescent Medicine Clinic at Children’s Hospital New Orleans has implemented the workflow shown in Figure 1. At check-in, the patient and parents or guardians receive a copy of the Adolescent Patients’ Bill of Rights and the Confidential Workflow handout. The patient is taken to the exam room where the vital signs and screening surveys are performed without the parent in the room. Once completed, the parent is brought into the exam room with the patient. The provider begins the visit with both patient and parent present and then will ask the parent to step out of the room for further discussion with the patient and the examination.
There are many pitfalls that need to be avoided in an office environment. Staff need to be trained to be cautious when discussing reasons for a visit at check-in or triage and when reconciling medications or reviewing after-visit summaries with the parent present. Additionally, staff need to ensure they do not send appointment reminders or follow-up surveys to parental contact numbers or e-mails for confidential visits.
EHR documentation for adolescents
Most EHRs do not by default integrate tools for keeping elements of the adolescent record and the corresponding patient portal confidential. In many adolescent clinics, providers have taken the time and effort to work with their Health Information Management (HIM) departments to preserve the confidentiality of patients. For example, in many clinics adolescents become the owner of their patient portal at an age designated by the institution and grant proxy access to parents to enable them to review all or a portion of the information contained therein (Figure 2).
Many institutions have a list of common labs performed on adolescents that are not transmitted to the patient portal. Some EHRs can be configured such that all adolescent notes are written in separate confidential notes that trigger a warning when accessed, indicating to the viewer that the information contained therein is provided on a “need-to-know” basis. Additionally, many clinics do not include adolescent visits when charts are copied unless approved by a physician. Some institutions choose to turn off portal access during this sensitive period, which may undermine communication with providers.
Insurance companies and confidentiality
Confidentiality of adolescent patients often breaks down because there is no universal policy regarding billing standards to ensure parents/guardians (policyholders) will not view sensitive information in adolescents’ Explanation of Benefits (EOB). It is the position of the Society for Adolescent Health and Medicine (SAHM), the AAP, and the American College of Obstetricians and Gynecologists (ACOG) that policies should be developed to not impede the provision of confidential healthcare to adolescent patients.
To this end, these organizations recommend that EOBs should not be required when individuals obtain “sensitive services.” Approaches include sending EOBs for these services directly to the patient and utilizing minor consent laws to direct insurance companies to use specific language in EOBs. The EOBs for such services can be designated as “adolescent health services” without detailing the services provided.8 As insurance laws/regulations are state based, there is much to be done legislatively at the state and federal levels to protect the confidentiality of adolescent patients. We recommend working with your state chapter of the AAP to achieve this goal.
In this brief article, we have reviewed ways pediatricians can create an effective confidentiality policy for adolescent patients and a workflow to implement that policy. Motivated pediatricians also will work within their practices to safeguard confidentiality in their practice EHRs and patient portals as well.
1. National Research Council (US) and Institute of Medicine (US) Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention, and Healthy Development; Lawrence RS, Appleton Gootman J, Sim LJ, eds. Adolescent Health Services: Missing Opportunities. Washington, DC: National Academies Press (US); 2009. Available at: https://www.ncbi.nlm.nih.gov/books/NBK215423/. Accessed March 6, 2019.
2. Committee on Adolescence. Achieving quality health services for adolescents. Pediatrics. 2016;138(2):e20161347.
3. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in health care: a survey of knowledge, perceptions and attitudes among high school students. JAMA. 1993:269(11):1404-1407.
4. Ginsberg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA. 1995;273(24):1913-1918.
5. Ford CA, Millstein SG, Halpern-Feisher B, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA. 1997;278(12):1029-1034.
6. Thrall JS, McCloskey L, Ettner SL, Rothman E, Tighe JE, Emans SJ. Confidentiality and adolescents’ use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med. 2000;154(9):885-892.
7. Grilo SA, Catallozzi M, Santelli JS, et al. Confidentiality discussions and private time with a health-care provider for youth, United States, 2016. J Adolesc Health. 2019;64(3):311-318.
8. Society for Adolescent Health and Medicine; American Academy of Pediatrics. Confidentiality protections for adolescents and young adults in the health care billing and insurance claims process. J Adolesc Health. 2016;58(3):374-377.