Implementing a universal informed consent process for the All of Us Research Program

The United States' All of Us Research Program is a longitudinal research initiative with ambitious national recruitment goals, including of populations traditionally underrepresented in biomedical research, many of whom have high geographic mobility. The program has a distributed infrastructure, with key programmatic resources spread across the US. Given its planned duration and geographic reach both in terms of recruitment and programmatic resources, a diversity of state and territory laws might apply to the program over time as well as to the determination of participants' rights. Here we present a listing and discussion of state and territory guidance and regulation of specific relevance to the program, and our approach to their incorporation within the program's informed consent processes.

HIPAA's Individual Right of Access to Genomic Data: Reconciling Safety and Civil Rights

In 2014, the United States granted individuals a right of access to their own laboratory test results, including genomic data. Many observers feel that this right is in tension with regulatory and bioethical standards designed to protect the safety of people who undergo genomic testing. This commentary attributes this tension to growing pains within an expanding federal regulatory program for genetic and genomic testing. The Genetic Information Nondiscrimination Act of 2008 expanded the regulatory agenda to encompass civil rights and consumer safety. The individual access right, as it applies to genomic data, is best understood as a civil-rights regulation. Competing regulatory objectives-safety and civil rights-were not successfully integrated during the initial rollout of genomic civil-rights regulations after 2008. Federal law clarifies how to prioritize safety and civil rights when the two come into conflict, although with careful policy design, the two need not collide. This commentary opens a dialog about possible solutions to advance safety and civil rights together.

Readability Level of Health Insurance Portability and Accountability Act Notices of Privacy Practices Utilized by Academic Medical Centers

Recently enacted Health Insurance Portability and Accountability Act legislation requires health care professionals to provide patients with a “Notice of Privacy Practices” (NPP) document as part of their informed consent process to participate in assessment and treatment. We were interested in the readability of these forms. We attempted to find a NPP from an academic medical center in each state plus the District of Columbia where documents were placed on the institution's Web site. Documents were obtained from 40 jurisdictions and were then analyzed utilizing two measures of readability. The majority (65%) of these documents were written beyond the 12thgrade reading level, and almost the entire sample (90%) fell in the difficult range of reading ease. Academic medical centers have an ethical obligation to improve the readability of these documents and should do so to improve clinical practice and reduce liability.

Shopping for a Transplant: When Noncompliant Patients Seek Wait Listing at Multiple Hospitals

United Network for Organ Sharing policy allows patients to be listed for a transplant at multiple hospitals. This strategy can sometimes lessen the transplant waiting time for patients because waiting times vary geographically. We explore the ethical dilemma of “shopping for a transplant” by presenting the case of a patient with an addictive disorder who was listed for liver transplantation at one hospital on the east coast of the United States and was seeking listing at 2 additional hospitals in midwestern United States, when marijuana use was suspected by 1 of the latter 2 facilities. Although the transplant team at this facility deferred listing the patient, the team's bioethicist posed the concept of a duty to notify the facility where the patient was already listed for transplantation about any confirmed substance abuse, in an effort to prevent a scarce resource from being allocated to an individual who is noncompliant.

Zip it!

When it comes to enforcing HIPAA data security and privacy standards, the federal government means business. In fact, the government is conducting a national pilot program to audit 150 physicians and others that HIPAA covers as the first phase of a concerted effort to crack down on HIPAA violations.

Privacy versus public health: the impact of current confidentiality rules

Public health research and practice often have been facilitated through the evaluation and study of population-based data collected by local, state, and federal governments. However, recent concerns about identify theft, confidentiality, and patient privacy have led to increasingly restrictive policies on data access, often preventing researchers from using these valuable data. We believe that these restrictions, and the research impeded or precluded by their implementation and enforcement, have had a significant negative impact on important public health research. Members of the public health community should challenge these policies through their professional societies and by lobbying legislators and health officials to advocate for changes that establish a more appropriate balance between privacy concerns and the protection of public health.

Internet-based Neuro-oncology Patient Recruitment

THE PRIVACY RULE, as part of the Health Insurance Portability and Accountability Act, was implemented in 2003 as a response to public concern over potential abuses of private health information. Although the Privacy Rule was not intended to place limits on clinical research, its complexity has caused much confusion throughout the academic medicine and research communities. Many clinical and translational researchers have created clinical databases or human tissue banks to facilitate future research. Maintenance of such databases is considered a research activity under the Privacy Rule, and researchers are, therefore, subject to its regulations. We present a novel Internet-based method to generate and maintain a neurooncology patient registry and human tissue bank. Through our web site, we secure both Health Insurance Portability and Accountability Act research authorization and informed consent, enabling us to contact the treating physician for clinical data and pathological specimens. Considering the importance of continued use of clinical databases and tissue banks in the genetic era of medicine, our method offers one way for researchers to adapt to the changing world of clinical research.

A cross-section of readability of Health Information Portability and Accountability Act authorizations required with health care research

The Health Information Portability and Accountability Act (HIPAA) regulations require that agencies provide authorizations that can be read and understood. Agencies are responsible to comply with this regulation. It is estimated that half of Americans read at an eighth-grade reading level. All institutional review boards (IRBs) listed on the website of the U.S. Department of Health and Human Services were contacted by investigators in this study. Fifty-one IRBs returned HIPAA templates on which readability tests could be completed. Three readability tests were used on all templates, including the Flesch Reading Ease formula, the Dale-Chall formula, and the Fry formula. For the returned templates, the mean of the Dale-Chall readability formula gave a ninth-grade level; the mean scores for the Flesch Reading Ease and Fry formulas were at a high-school reading level or above. The readability scores ranged from sixth-grade to college graduate. This study demonstrates that HIPAA authorization forms are written at too high a level for most of the population. Based on the results of this study and other similar studies, it can be concluded that consumers/patients are currently being asked to read important health-related documents that may be beyond their reading level.

Compliance with HIPAA Regulations: Ethics and Excesses

HIPAA regulations have been seen by many physicians as providing innumerable administrative hoops that require jumping through with no clear benefit for individual patients. Although this article has not comprehensively explored the requirements of HIPAA regulations, it has focused on the issues of "incidental disclosures" that are so important to the daily interactions of physicians and patients. Through the use of illustrative cases, it has been shown that HIPAA regulations frequently are based on well-accepted ethical principles. Although one should never conclude that changing something from an ethical responsibility to a legal responsibility makes it more important, there is no question that HIPAA regulations have forced physicians to consider more carefully how confidential information may be transmitted to others. As such, physicians should look on HIPAA regulations as largely supporting the use of professional judgment in providing good quality medical care. Although not all aspects of HIPAA are grounded in ethical practices, the overall thrust of the HIPAA regulations is consistent with the ethical practice of medicine and surgery. As a result of this general alignment of the legal and ethical requirements, more attention should be directed by physicians at using good judgment in deciding how to disclose private information, rather than adopting an unreasonable approach that confidentiality may never be breached. As Lo and colleagues have very appropriately pointed out: In the context of inadvertent disclosure, the legal risks of good practice are very low. Physicians should work with risk managers and practice administrators to develop policies that promote good communication in patient care, while taking appropriate steps to protect patient privacy. By adopting such an approach to HIPAA, physicians can abide by the regulations while maintaining high ethical standards and minimizing the impact of the new requirements on physician-patient relationships.

HIPAA--Implications for research

Privacy, anonymity, and informed consent are the hallmarks of current research conduct. How do the Health Insurance Portability and Accountability Act regulations regarding individually identified health information and protected health information affect research? The purpose of this article is to discuss ways that the Health Insurance Portability and Accountability Act is influencing the conduct of research, including the implications for institutional review boards, recruitment of subjects, obtaining consent, access to data, de-identification of data, authorization to disclose data, and the processing, transmission, and storage of collected data.

e-Ethics: new dilemmas emerge alongside new technologies

As new informational technologies emerge and ever more innovative applications of existing technologies are found, new circumstances will also evolve. The ethical issues involved in these situations will challenge forward-looking nurse leaders to become aware of the matters in question and to employ critical thinking to ensure that information technology serves all stakeholders well.

From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine--Part I: conceptual, moral, and legal foundations

Respect for patient privacy and confidentiality is an ancient and a contemporary professional responsibility of physicians. Carrying out this responsibility may be more challenging and more important in the emergency department than in many other clinical settings. Part I of this 2-part article outlines the basic concepts of privacy and confidentiality, reviews the moral and legal foundations and limits of these concepts, and highlights the new federal privacy regulations implemented under the Health Insurance Portability and Accountability Act of 1996. Part II of the article examines specific privacy and confidentiality issues commonly encountered in the ED.

HIPAA???Clinical and Ethical Considerations for Nurses

Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) to protect patients' basic rights to privacy and their control over the disclosure of their personal health information. Advances in and the more widespread use of communication technology were increasing the public's concerns over the ease with which their health information could be transmitted, how protected that information was during such transmissions, and their lack of approval for the use of that information by known and unknown third parties. This article, the first of two papers focusing on HIPAA, discusses HIPAA from the clinical perspective and focuses primarily on the HIPAA Privacy Rule. Under what circumstances can a covered entity disclose protected health information? What are the ethical issues inherent in HIPAA? What does HIPAA require of covered entities? What are the implications of HIPAA for professional nurses? The goal of HIPAA is to ensure the protection of confidential health information through having appropriate security systems to guard against unintentional disclosure of that information.

E-mail consultation: clinical, financial, legal, and ethical implications

BACKGROUND

Communication via e-mail has become widespread. Nearly every practicing neurosurgeon is confronted with numerous unsolicited e-mail requests for medical advice, guidance, or information. Neurosurgeons need to be aware of the clinical, financial, legal, and ethical implications of providing medical consultation via e-mail.

METHODS

A literature review of the penetration of e-mail consultation in medical practice was performed. The data on the potential for reimbursement for provision of these services is presented. Precedents for legal liability are discussed, and issues of compliance with HIPAA regulations are reviewed.

RESULTS

Communication between patients and physicians via e-mail is increasing in prevalence, and a substantial number of physicians are providing medical information via e-mail consultation. Billing for online consultation has been approved by the American Medical Association, and several medical insurance carriers are evaluating the economic consequences of reimbursement for e-mail consultation. E-mail consultation raises potential medico-legal concerns, including establishment of the physician-patient relationship, malpractice liability, and HIPAA compliance.

CONCLUSIONS

The increasing prevalence of e-mail consultation raises new concerns for neurosurgeons. Some of these concerns have yet to be addressed by regulatory commissions or in the courts. If used appropriately, e-mail communication can facilitate physician-patient interactions, improve access to care, save time for each interaction, and possibly reduce costs of care.

The impact of fear of HIPAA violation on patient care

The deadline for compliance with the privacy rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was April 14, 2003. Understandably, many psychiatrists and other mental health providers have been focusing on compliance. This brief report discusses the negative impact of efforts to implement HIPAA on patient care in a community-based mental health system. Three cases highlight several issues: fear of violating HIPAA, failure to understand HIPAA's privacy regulations, and ethical concerns. The authors discuss the key issues and address implications for practice. Several recommendations are offered for maintaining excellent patient care while complying with HIPAA.

Confidentiality of employee health records: ethical and legal dilemmas for occupational health nurses

Health professionals must be familiar with regulations and statutes addressing privacy and confidentiality issues. The occupational health nurse must also be aware of specific limitations and exceptions to confidentiality. Occupational health nurses must become proactive in governmental affairs to lobby for changes to include workplace health records in future legislation. To ensure employee trust, occupational health nurses must maintain their ethical and legal responsibility to act morally when making decisions related to confidentiality. The AAOHN Code of Ethics and Interpretive Statements and the AAOHN Position Statement on Confidentiality of Health Information can be used as frameworks to guide occupational health nursing practice.

Privacy in psychiatric treatment: threats and responses

OBJECTIVE

The author provides an overview of the current status of privacy in psychiatric treatment, with particular attention to the effects of new federal regulations authorized by the Health Insurance Portability and Accountability Act (HIPAA).

METHOD

The author reviews the ethical and legal underpinnings for medical privacy, including the empirical data supporting its importance; discusses those portions of the new federal regulations most relevant to psychiatric practice; and suggests steps that psychiatrists can take to maintain their patients' privacy in the new environment.

RESULTS

Medical ethics and law, in keeping with patients' preferences, traditionally have provided strong protection for the information that patients communicate while receiving medical care. In general, release of information has required patients' explicit consent. However, limitations of the consent model and technological innovations that permit the aggregation of computerized medical information have led to pressure for greater access to these data. Although the new federal regulations offer patients some additional protections (including security for psychotherapy notes), they also mark a retreat from reliance on patient consent and open up records to previously unauthorized uses, among them law enforcement investigations and marketing and fundraising by health care organizations. However, states retain the power to provide higher levels of protection.

CONCLUSIONS

The new regulatory environment is less friendly to medical privacy but still leaves a great deal of discretion in physicians' hands. A commitment to protecting privacy as an ethical norm can be advanced by psychiatrists' requesting patients' consent even when it is not required, by ensuring that patients are aware of the limits on confidentiality, and by avoiding unnecessary breaches of privacy in the course of providing psychiatric care.

Patient privacy: how far is too far?

With few exceptions, personal privacy has long been an ethical right and legal mandate. Clinicians, policy makers, and consumers are challenged to find a balance between allowing consumers to be protected and allowing clinicians to meet patient care needs. This article examines the current debate pertaining to new Medical Privacy Guidelines that were issued in April 2001. The ethical principle of patient confidentiality, including the right to personal privacy, is reviewed along with its relationship to computer-generated wound care tracking programs that transcend practice settings. Options for Health Insurance Portability and Accountability Act (HIPAA) compliance are presented.