Maintaining adolescent confidentiality in care

Adolescence is a time of pushing boundaries and finding out who one is. It’s also a time when a patient may have concerns that they may want to discuss with the clinician without parents in the room. Questions of confidentiality and consent to care can be areas that give adolescent patients concerns. They want to know whether their parents are going to find out about being tested for sexually transmitted infections or discussing depression. During the presentation “Mum’s the word: Adolescent consent to care and confidentiality (and EHRs)” at the virtual 2020 American Academy of Pediatrics National Conference & Exhibition, Ryan H. Pasternak, MD, MPH, FAAP, professor of clinical pediatrics at the Louisiana State University School of Medicine in New Orleans, and Kirsten B. Hawkins, MD, MPH, FAAP, FSAHM, discussed how the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule affects adolescent confidentiality, the 21st Century CURES act and electronic health records, and how their health systems protected adolescent confidentiality.

Pasternak discussed how HIPAA’s Privacy Rule can protect adolescent confidentiality. Patients aged 13 years or older can request special privacy protections, which can include requesting clinicians and health plans communicate in a confidential manner and request limitations on the disclosure of information regarding treatment or payment. There are also certain situations when a parent may no longer be a representative of the minor, such as health care services for contraception. For a more in-depth discussion on HIPAA’s Privacy Rule and teenagers, Pasternak recommended an article from the Guttmacher Institute. Hawkins spoke on the CURES act, which is meant to make access to health records easier than before and serves as an enhancement to HIPAA.

During a report on how his health system had managed adolescent confidentiality, Pasternak briefly covered why it’s important, including adolescents are more likely to see a clinician; issues that may prompt a need for confidentiality such as alcohol use and suicidality are leading causes of illness or death among teenagers; and follow-up care is more likely to occur. He then discussed what his system’s confidential workflow looked like: front-desk staff informs patient and parents about adolescent confidentiality right; vital signs and screenings are performed without parents; patient and clinician discuss any screening information before bringing parents into the room; and parents and patient start the visit with the clinician, but parents are asked to return to the waiting room to allow for a confidential discussion.

In Hawkin’s health care system, patients aged younger than 18 can have access to their medical records if they can provide documentation showing that they are emancipated or if the parent approves access to the patient portal. This approval needs to be done in person and recognizes that the adolescent will have full access to the portal. Parents can request proxy access to their adolescent child’s records, but the access only allows the parent to review immunization data, not the full medical record. Proxy access is removed once the patient turns 18 years of age.

The presentation concluded with a number of cases. Pasternak and Hawkins discussed whether the case represented a HIPAA violation, what went wrong in the case, and how the issue could have been prevented.