Title: St. Joseph's v. Cardiac Surgery

State: maryland

Issuer: Maryland Supreme Court

Document:

IN THE COURT OF APPEALS OF MARYLAND
No. 64
September Term, 2003
_________________________________________
ST. JOSEPH MEDICAL CENTER, INC.
v.
CARDIAC SURGERY ASSOCIATES, P.A.,
et al.
__________________________________________
Bell, C.J.
       
Raker
Wilner
Cathell
Harrell
Battaglia
Eldridge, John C. (Retired, Specially
 Assigned),
                  JJ.
__________________________________________
Opinion by Eldridge, J.
_________________________________________
Filed:   April 12, 2006
This case involves a challenge to a trial court’s discovery order requiring the
production of several internal hospital documents.  The documents consist of e-mails,
correspondence, letters, and testimony by hospital staff, regarding incidents which staff
members believed should be investigated by a medical review committee, i.e., a peer
review group which monitors the quality of health services at the hospital.  At issue is
whether the documents are protected by the medical review committee privilege, which
shields records, proceedings and files of such committees from discovery and
admissibility in civil actions.  We are also presented with the threshold question of
whether the trial court’s discovery order is appealable by the hospital, known as
St. Joseph Medical Center, Inc.  We shall hold that the order is appealable by
St. Joseph, and we shall, on the merits, reverse the trial court’s order.
I.
On October 17, 2001, Cardiac Surgery Associate s, P.A., filed an action in the
Circuit Court for Baltimore County against MidAtlantic Cardiovascular Associates,
P.A., alleging unfair competition and tortious interference with economic relations in
connection with the parties’ cardiac surgery practices.  Cardiac Surgery and
MidAtlantic both employ cardiac surgeons who practice extensively at St. Joseph
Medical Center, Inc.  St. Joseph, however, is not a party to the unfair competition
lawsuit.
Both sides in the unfair competition action sought discovery from St. Joseph by
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1
Of those 118 documents, 117 of them had been produced by Cardiac Surgery and one had been
produced by MidAtlantic.
2
It is unclear how the parties gained control of the documents; however, employees of both
Cardiac Surgery and MidAtlantic had access to many of the documents because they had participated
in the peer review process of the medical review committees at St. Joseph.  In fact, Dr. Garth
McDonald, Cardiac Surgery’s president, served as chief of the division of cardiac surgery at
St. Joseph and wrote or received many of the contested documents in that capacity.
serving upon the hospital notices of deposition and subpoenas duces tecum.  In
response, St. Joseph produced over 29,000 pages of documents.  Additionally,
St. Joseph produced a privilege log, identifying those documents which it would not
produce because, according to St. Joseph, they were covered by certain privileges,
including the medical review committee privilege set forth in Maryland Code (1981,
2005 Repl. Vol.), § 1-401(d)(1) of the Health Occupations Article.  St. Joseph’s
assertion of privilege was not challenged by either party during the discovery process.
St. Joseph later learned that 118 documents, which were listed in its privilege
log, had been exchanged by the parties during discovery.1  St. Joseph wrote to each of
the parties and advised them that the 118 documents in their possession were
privileged, that the documents had improperly come into the custody of the parties, and
St. Joseph demanded the immediate return of the documents to the hospital. 2
When the documents were not returned, St. Joseph commenced the present action
by filing in the Circuit Court for Baltimore County a motion for a protective order,
asserting that the medical review committee privilege protected the 118 documents.
St. Joseph requested the court to disallow the use of those documents at the trial of the
unfair competition case and order the parties in that case to return them to the hospital.
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MidAtlantic filed a response, consenting to the relief sought by St. Joseph, as it had
already returned the one document in its possession.
Cardiac Surgery responded to St. Joseph’s motion by arguing that the medical
review committee privilege did not apply to any of the documents listed in St. Joseph’s
privilege log, including the 118 documents which had been produced by the parties in
the underlying suit.  Cardiac Surgery further argued that, even if the privilege applied,
the allegations of unfair competition in the underlying litigation outweighed any
interest St. Joseph had in protecting the documents.  In making this argumen t, Cardiac
Surgery chiefly relied on Price v. Howard County General Hospital, 950 F.Supp. 141
(D.Md. 1996).
The Circuit Court granted St. Joseph’s motion for a protective order in part and
denied it in part.  Initially, the court held that 19 of the 117 documents in Cardiac
Surgery’s possession were not protected by the medical review committee privilege
under § 1-401(d) of the Health Occupations Article.  St. Joseph then withdrew its claim
of privilege as to 5 of the disputed documents, in which the names of its patients had
been redacted.  Therefore, there are 14 of the documents in Cardiac Surgery’s
possession which have remained at issue.  In addition to these 14 documents, the
Circuit Court ordered that St. Joseph produce other documents, namely
“all of the documents contained in [St. Joseph’s] ‘privilege log,’
. . . which are labeled ‘peer review,’ or ‘utilization’ are
discoverable as they do not come within the meaning of medical
review committee materials as meant by the Maryland legislature
for reasons discussed below.”
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The Circuit Court, in an accompanying opinion, explained its order as follows
(emphasis in original):
“In its ruling this Court is fully cognizant and respectful of the
need and purpose underlying the medical review committee
privilege as codified in Maryland Health Occupations Article, § 1-
401 (2002).  That purpose is to ‘ensure a high quality of peer
review activity leading to the primary goal . . . to provide better
health care.’  Unnamed Physician v. Committee on Medical
Discipline, 285 Md. 1 (1979). * * * Nevertheless, the Court finds
that the materials that [St. Joseph] seeks to protect are not materials
instituted by an act of a committee for the purpose intended by the
statute.  These materials are emails, letters, correspondences, and
testimony of certain hospital staff, mostly nurses, regarding
incidents they had personally witnessed and issues they feel should
be addressed or investigated.  There has been no indication that
these materials are the result of or involved in such an
investigation by a peer review or medical review committee, which
would certainly be privileged.  These materials are not documented
disciplinary records or proceedings or files or notes or minutes of
the medical review committee under § 1-401(d) of the statute.
Rather, they are themselves observations and concerns, as yet not
proven to be true, that tend to show that certain conduct of
Defendant [in the unfair competition litigation], namely patient
diversion and self-referral, might not be in a patient’s best interest,
and more important, that may be unlawfu l.  Additionally, the
material is directly relevant to the allegations made by Plaintiff
[Cardiac Surgery], namely that Defendant [is] intentionally
engaging in unfair competition, and are not materials intended to
publicly disparage, or call into question, a doctor’s medical ability.
Therefore, their discoverab ility will have no chilling effect on the
purpose of the privilege.
“This Court agrees with the reasoning of the United States
District Court for the District of Maryland, which found that
Maryland’s medical review committee privilege did not apply to a
federal antitrust claim because ‘the driving force behind the federal
antitrust laws – free competition, outweigh the policies underlying
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the privilege.’  Price v. Howard County General Hospital, 950 F.
Supp. 141 (1996).  Maryland’s unfair competition laws are akin to
the federal laws and attempt to enforce the same policy, preserving
free competition.  In this case, the Court finds that the policy of
lawful competition outweighs the policy of the privilege.”
St. Joseph noted an appeal to the Court of Special Appeals, challenging the
Circuit Court’s order with regard to the 14 documents in Cardiac Surgery’s possession
and with regard to the other documents listed in the privilege log which the Circuit
Court held were discoverable.  The Court of Special Appeals initially ordered that
St. Joseph produce for the appellate court the documents at issue, but the appellate
court later rescinded this order.  Cardiac Surgery filed a motion to dismiss the appeal,
arguing that the trial court’s order was not appealable as a final judgment and that it did
not fall within the collateral order doctrine.  In its motion, Cardiac Surgery asserted that
the only way for St. Joseph to appeal such an order would be to refuse to comply with
the order and then be adjudicated in contempt of court.  In its response, St. Joseph
argued that a finding of contempt was not necessary to trigger its right to appeal the
Circuit Court’s order and that the order was appealable as a final judgment under this
Court’s decision in Department of Social Services v. Stein, 328 Md. 1, 612 A.2d 880
(1992).  The Court of Special Appeals denied the motion to dismiss, without prejudice
to the parties’ right to reassert the appealability argumen ts in their briefs.  
Before any further proceedings in the Court of Special Appeals, this Court issued
a writ of certiorari.  St. Joseph Medical v. Cardiac Surgery, 377 Md. 275, 833 A.2d 31
(2003).  The parties in briefs and oral argumen t, in addition to addressing the merits of
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the Circuit Court’s order, reiterate their contentions with respect to appealability.
II.
We shall first address Cardiac Surgery’s motion to dismiss St. Joseph’s appeal.
A.
As this Court has emphasized on numerous occasions, very recently by Judge
Raker for the Court in Nnoli v. Nnoli, 389 Md. 315, 323, 884 A.2d 1215, 1219 (2005),
“[t]he general rule as to appeals is that, subject to a few, limited exceptions, a party
may appeal only from a final judgment.”  See Maryland Code (1974, 2002 Repl. Vol.),
§ 12-301 of the Courts and Judicial Proceedings Article.  Moreover, under Maryland
law, the “few, limited exceptions” to the final judgment rule number only three.  Judge
Wilner for the Court in Salvagno v. Frew, 388 Md. 605, 615, 881 A.2d 660, 666 (2005),
explained:
“[W]e have made clear that the right to seek appellate review of a
trial court’s ruling ordinarily must await the entry of a final
judgment that disposes of all claims against all parties, and that
there are only three exceptions to that final judgment requirement:
appeals from interlocutory orders specifically allowed by statute;
immediate appeals permitted under Maryland Rule 2-602; and
appeals from interlocutory rulings allowed under the common law
collateral order doctrine.”
See, e.g., Board of Education v. Bradford, 387 Md. 353, 382-386, 875 A.2d 703, 720-
723 (2005); In re Billy W., 386 Md. 675, 688-692, 874 A.2d 423, 430-434 (2005);
Smith v. Lead Industries, 386 Md. 12, 21-23, 871 A.2d 545, 550-551 (2005); In re
Samone H., 385 Md. 282, 297-298, 869 A.2d 370, 378-379 (2005); Edwards v. Corbin,
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379 Md. 278, 286 n.4, 841 A.2d 845, 850 n.4 (2004); Frase v. Barnhart, 379 Md. 100,
115, 840 A.2d 114, 122-123 (2003); Dawkins v. Baltimore City Police Departm ent, 376
Md. 53, 58, 827 A.2d 115, 117-118 (2003); Montgomery Co. v. Stevens, 337 Md. 471,
476-477, 654 A.2d 877, 879-880 (1995); Public Service Comm’n v. Patuxent Valley,
300 Md. 200, 207, 77 A.2d 759, 763 (1984).
Cardiac Surg ery, in arguing that the Circuit Court’s decision is not appealable
by St. Joseph, views the Circuit Court’s order as if it were solely an interlocutory
discovery order in the underlying unfair competition tort case.  Thus, according to
Cardiac Surg ery, the order is not appealable as a final judgment and does not fall within
any statute permitting interlocutory appeals.  Cardiac Surgery maintains that the sole
argument for appealability would be the collateral order doctrine, but that “the elements
of the collateral order doctrine are not established.”  (Cardiac Surgery’s brief at 2). 
If this discovery dispute were only between parties to the underlying unfair
competition action, we would agree with Cardiac Surgery that no party to that action
could take an immediate appeal from the discovery order.  Under such circumstances,
the order would be entirely interlocutory, and any appeal challenging the order would
have to be by an aggrieved party after the final judgment terminating the unfair
competition action in the trial court.
B.
Furthermore, Cardiac Surgery correctly argues that the Circuit Court’s order is
not appealable under the collateral order doctrine.  That doctrine is inapplicable in this
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case.
The collateral order doctrine allows, under extremely limited circumstances, an
appeal from a trial court’s interlocutory order by a party aggrieved by that order.  The
doctrine was summarized in Nnoli v. Nnoli, supra, 389 Md. at 329, 884 A.2d at 1223,
as follows:
“The collateral order doctrine treats as final and appealable
interlocutory orders that (1) conclusively determine the disputed
question; (2) resolve an important issue; (3) resolve an issue that
is completely separate from the merits of the action; and (4) would
be effectively unreview able on appeal from a final judgment.
Dawkins v. Baltimore Police, 376 Md. 53, 58, 827 A.2d 115, 118
(2003).  The collateral order doctrine is a very narrow exception to
the final judgment rule, and each of its four requirements is very
strictly applied in Maryland.  Id. at 58-59, 827 A.2d at 118.  In
particular, the fourth prong, unreviewability on appeal, ‘is not
satisfied except in “extraordinary situations.”’  Shoemaker v.
Smith, 353 Md. 143, 170, 725 A.2d 549, 563 (1999) (quoting
Bunting v. State, 312 Md. 472, 482, 540 A.2d 805, 809 (1988))
. . . .”
The collateral order doctrine was further described in Dawkins v. Baltimore City
Police Departm ent, supra, 376 Md. at 64, 827 A.2d at 121 (footnote omitted):
“The collateral order doctrine is based upon a judicially created
fiction, under which certain interlocutory orders are considered to
be final judgments, even though such orders clearly are not final
judgments.  The justification for the fiction is a perceived
necessity, in ‘a very few . . . extraordinary situations,’ for
immediate appellate review.”  Quoting Bunting v. State, 312 Md.
472, 482, 540 A.2d 805, 809 (1988).
See also, e.g., In re Foley, 373 Md. 627, 634, 820 A.2d 587, 591 (2003) (“[I]n
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Maryland the four requirements of the collateral order doctrine are very strictly applied,
and appeals under the doctrine may be entertained only in extraordinary
circumstances”); In re Franklin P., 366 Md. 306, 327, 783 A.2d 673, 686 (2001) (“The
four elements of the test are conjunctive in nature and . . . each of the four elements
must be met”); Pittsburgh Corning v. James, 353 Md. 657, 660-661, 728 A.2d 210,
211-212 (1999); Shoemaker v. Smith, 353 Md. 143, 169, 725 A.2d 549, 563 (1999).
It is firmly settled in Maryland that, except in one very unusual situation,
interlocutory discovery orders do not meet the requirements of the collateral order
doctrine and are not appealable under that doctrine.  Most discovery orders do not
comply with the third requirement of the collateral order doctrine, as they generally are
not completely separate from the merits of the lawsuit.  Instead, “a typical discovery
order [is] aimed at ascertaining critical facts upon which the outcome of the . . .
controversy might depend.”  In re Foley, supra, 373 Md. at 635, 820 A.2d at 587.  In
addition, discovery orders fail to meet the collateral order doctrine’s fourth element,
as they are effectively reviewable on appeal from a final judgment.  In re Foley, ibid.
A party aggrieved by a discovery order and aggrieved by the final judgment may
challenge the discovery ruling on appeal from the final judgment.  Furthermore,
discovery orders rarely involve an “extraordinary situation” which is part of the
collateral order doctrine’s fourth element.  Foley, 373 Md. at 636, 820 A.2d at 593.
As this Court concluded in the Foley opinion, 373 Md. at 636, 820 A.2d at 592-
593, 
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3
In re Foley, supra, 373 Md. at 636, 820 A.2d at 593.
“we have made it clear that discovery orders are only rarely
appealable under the collateral order doctrine.  The only
circumstance in which we have upheld the appealability of
interlocutory discovery orders involves a singular situation far
removed from the facts of the instant case.  Montgomery Co. v.
Stevens, supra, 337 Md. 471, 654 A.2d 877; Public Service
Comm’n v. Patuxent Valley, supra, 300 Md. 200, 477 A.2d 759.”
See also Goodrich v. Nolan 343 Md. 130, 141 n.8, 680 A.2d 1040, 1045 n.8 (1996) (“In
Maryland, ‘discovery orders, being interlocutory in nature, are not ordinarily appealable
prior to a final judgment terminating the case’”); Departm ent of Social Services v.
Stein, supra, 328 Md. at 7, 612 A.2d at 883 (“[T]he order from which it has appealed
is a discovery order, which normally is interlocutory and, consequently,
nonappealable”); Price v. Orrison, 261 Md. 8, 9, 273 A.2d 183, 184 (1971) (Order
denying “several motions to prevent the taking of depositions” was “interlocutory in
nature and not falling within one of the statutory categories of appealable non-final
orders;” thus the appeal was dismissed).
The “singular situation,”3 in which this Court has held that interlocutory
discovery orders are appealable under the collateral order doctrine, involves trial court
orders permitting the depositions of high level governmental decision makers for the
purpose of “‘extensive[ly] probing . . . their individual decisional thought processes.’”
Montgomery Co. v. Stevens, supra, 337 Md. at 479, 654 A.2d at 881, quoting Public
Service Comm’n v. Patuxent Valley, supra, 300 Md. at 207, 477 A.2d at 763.  The order
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4
Rule 2-403 provides as follows (emphasis added):
“Rule 2-403. Protective orders.
(a) Motion.- On motion of a party or of a person from whom discovery is
sought, and for good cause shown, the court may enter any order that justice requires
to protect a party or person from annoyance, embarrassment, oppression, or undue
burden or expense, including one or more of the following: (1) that the discovery not
be had, (2) that the discovery not be had until other designated discovery has been
completed, a pretrial conference has taken place, or some other event or proceeding
has occurred, (3) that the discovery may be had only on specified terms and
conditions, including an allocation of the expenses or a designation of the time or
place, (4) that the discovery may be had only by a method of discovery other than that
selected by the party seeking discovery, (5) that certain matters not be inquired into
or that the scope of the discovery be limited to certain matters, (6) that discovery be
conducted with no one present except persons designated by the court, (7) that a
deposition, after being sealed, be opened only by order of the court, (8) that a trade
(continued...)
in the present case obviously does not fall within this category.
C.
Our conclusion that the Circuit Court’s discovery order is not appealable under
the collateral order doctrine, however, does not end the question of appealability.
Although the discovery order was interlocutory with regard to the underlying
unfair competition litigation and the parties to that case, the order was not interlocutory
with regard to St. Joseph.  St. Joseph is not a party to the unfair competition case and
would have no standing to challenge the discovery order by appealing from a final
judgment in that case. See Lopez-Sanchez v. State, 388 Md. 214, 224, 879 A.2d 695,
701 (2005)(“A salient feature of [the general appeals] statute[] is that the grant of
appellate rights extends only to parties”).  The only proceeding in which St. Joseph is
a party is the “motion for a protective order” proceeding pursuant to Maryland Rule 2-
403.4  The Circuit Court’s order finally terminated that proceeding adversely to
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4
(...continued)
secret or other confidential research, development, or commercial information not be
disclosed or be disclosed only in a designated way, (9) that the parties simultaneously
file specified documents or information enclosed in sealed envelopes to be opened
as directed by the court. 
(b) Order.- If the motion for a protective order is denied in whole or in part,
the court may, on such terms and conditions as are just, order that any party or person
provide or permit discovery.”
St. Joseph.  Analytically, and under our cases, the order was final as to St. Joseph and
was appealable by St. Joseph as a final judgment.  Under the circumstances here, and
unlike the law in some other jurisdictions, Maryland law does not require a person or
entity in St. Joseph’s position to refuse compliance with the court’s order, and be held
in contempt, in order to challenge on appeal the adverse order.
Department of Social Services v. Stein, supra, 328 Md. 1, 612 A.2d 880, is
factually similar to the case at bar and very much on point.  In Stein, there was pending
in the Circuit Court for Baltimore City a tort action brought by tenants of residential
property against their landlord, seeking damages for injuries to the tenants’ child
caused by lead paint poisoning.  The defendant landlord had a subpoena issued to the
Baltimore City Department of Social Services, seeking records of the Department
relating to welfare payments to the plaintiffs and other records relating to the plaintiffs.
The Baltimore City Department of Social Services was not a party to the underlying tort
action.  The Department filed in the Circuit Court a motion for a protective order,
asserting that the records sought were confidential and protected by privilege.  The
Circuit Court denied the motion for a protective order, and the Department appealed.
The appellee Stein, arguing for the dismissal of the appeal, “question[ed] whether the
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order has the requisite finality since the appellant has not been held in contempt.”
Stein, 328 Md. at 8, 612 A.2d at 883.
This Court in Stein, in an opinion by Judge Bell, pointed out that the federal cases,
since the decision in Alexander v. United States, 201 U.S. 117, 26 S.Ct. 356, 50 L.Ed.
686 (1906), would support the position of the appellee Stein and would require that one
in the Department’s position be held in contempt in order to challenge the order on
appeal.  The Court in Stein went on to point out that “[w]e have declined to follow the
Alexander rule,” Stein, 328 Md. at 16, 612 A.2d at 887, and that “[t]he appellant’s right
to appeal is not dependent upon its being held in contem pt.”  328 Md. at 21, 612 A.2d
at 891.  In holding that the Department could appeal the order, the Court in Stein stated
(328 Md. at 13, 612 A.2d at 886):
“With regard to the appellant and the appellee, the ruling has all of
the attributes of finality recognized by this Court; it settles the
rights of the appellant and the appellee in the records sought to be
discovered . . . . The discovery order in this case determined and
concluded the appellant’s rights and interests in the discovery issue
and denied it the means of further prosecuting or defending them.”
In situations where the aggrieved appellant, challenging a trial court discovery
or similar order, is not a party to the underlying litigation in the trial court, or where
there is no underlying action in the trial court but may be an underlying administrative
or investigatory proceeding, Maryland law permits the aggrieved appellant to appeal
the order because, analytically, it is a final judgment with respect to that appellant.
See, e.g., State Prosecutor v. Judicial Watch, 356 Md. 118, 126, 737 A.2d 592, 596
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5
Cardiac Surgery also argues that St. Joseph lacked standing in the Circuit Court to file a motion
for a protective order under Rule 2-403.  Cardiac Surgery contends that St. Joseph was neither “a
party” nor “a person from whom discovery is sought” within the language of the Rule.  In our view,
St. Joseph qualified as a person from whom discovery was sought within the intent of the Rule.
(1999) (This Court pointed out that the order in the Stein case was appealable because
the appellant “was a non-party to the underlying action, as to whom the discovery
disclosure order had all the attributes of finality recognized by this Court”); Unnamed
Attorney v. Attorney Grievance Comm’n, 303 Md. 473, 480, 494 A.2d 940, 944
(1985)(“We have rejected the argument that, in this situation, one must be adjudged in
contempt of the court order in order to obtain appellate review”); In re Special
Investigation No. 231, 295 Md. 366, 370, 455 A.2d 442, 444 (1983); In re Special
Investigation No. 185, 293 Md. 652. 655-656 n.2, 446A.2d 1151, 1154 n.2 (1982); Fred
W. Allnut, Inc. v. Comm’r, Labor & Industry, 289 Md. 35, 41, 421 A.2d 1360, 1363
(1980).
Consequently, St. Joseph was entitled to appeal the Circuit Court’s order.  The
Court of Special Appeals correctly denied Cardiac Surgery’s motion to dismiss the
appeal, and we shall do likewise.5
III.
A.
The medical review committee privilege statute was first enacted by Ch. 722 of
the Acts of 1976, and codified as Maryland Code (1957, 1971 Repl. Vol., 1976 Supp.),
Art. 43, § 134A(d).  In 1981, as part of the general re-codification of some of the
statutes relating to health matters, the medical review committee privilege was re-
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codified, by Ch. 8 of the Acts of 1981, as § 14-601(d) and (e) of the Health
Occupations Article.  According to the Revisor’s Note, the 1981 re-codification was
“without substantive change from Art. 43, § 134A.”  See Laws of Maryland 1981 at
605.  
From 1976 until October 1, 1997, the critical language of the medical review
committee privilege remained unchanged.  It provided that “the proceedings, records,
and files of a medical review committee are not discoverab le and are not admissible in
evidence in any civil action arising out of matters that are being reviewed and
evaluated by the medical review committee.”  (Emphasis added).  By Ch. 696 of the
Acts of 1997, effective October 1, 1997, the above-quoted italicized limitation was
deleted so that the privilege applied “in any civil action” without limitation.
As a result of subsequent re-numbering of sections of the Health Occupations
Article, the medical review committee privilege is now codified as § 1-401(d) and (e)
of the Health Occupations Article.  The pertinent language of § 1-401(d) and (e) is as
follows:
“(d) Proceedings, records, and files confidential and not
admissible or discoverable. – (1) Except as otherwise provided in
this section, the proceedings, records, and files of a medical review
committee are not discoverab le and are not admissible in evidence
in any civil action.”
* * *
“(e) Same – Exceptions. – Subsection (d)(1) of this section does
not apply to: 
(1) A civil action brought by a party to the proceedings
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of the medical review committee who claims to be aggrieved by the
decision of the medical review committee; or
(2) Any record or document that is considered by the
medical review committee and that otherwise would be subject to
discovery and introduction into evidence in a civil trial.”
In Unnamed Physician v. Comm’n, 285 Md. 1, 12, 400 A.2d 396, 402 (1979),
Judge Cole for the Court indicated that the privilege would apply to “the matters
reviewed by a medical review committee” if the materials were sought in an action like
“a tort action for medical malpractice.”  With regard to the overall purpose of the
privilege, Judge Cole continued (285 Md. at 13, 400 A.2d at 403):
“A . . . fundamental reason for preserving confidentiality in these
proceedings is to ensure a high quality of peer review activity
leading to the primary goal of this legislation – to provide better
health care.”
The medical review committee privilege was again considered by this Court in
Baltimore Sun v. University of Maryland Medical System, 321 Md. 659, 584 A.2d 683
(1991).  This Court’s opinion in Baltimore Sun, written by Chief Judge Murphy,
reiterated what was said in the Unnamed Physician case, and reviewed with approval
numerous authorities emphasizing the importance and broad scope of the privilege
(321 Md. at 666-667, 584 A.2d at 686-687):
“The statutory protection afforded medical review committee
records by § 14-601(d) [now § 1-401(d)] is seemingly premised
upon and consistent with the view expressed in Comm ent, The
Medical Review Committee Privilege: A Jurisdictional Survey, 67
N.C.L.Rev. 179, at 179 (1988): ‘[P]hysicians are frequently
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reluctant to participate in peer review evaluations for fear of
exposure to liability, entanglement in malpractice litigation, loss of
referrals from other doctors, and a variety of other reasons.  To
combat this reluctance and to enhance the improvement of medical
care services, at least forty-six states now have statutes that protect
the work of medical review committees.’  Another commentator
noted that the major purpose behind the medical review committee
privilege is to permit the committee to work in a confidential
setting in which individual members may engage in a candid and
conscientious evaluation of clinical practices within the institution.
See Hall, Hospital Committee Proceedings and Reports: Their
Legal Status, 1 Am.J.L. & Med. 245, 25A-54 (1975).  Statutory
protection of peer review activities is supported by the notion that
they result in increased peer review activity and that such activity
improves medical care.  Comm ent, Medical Peer Review
Protection in the Health Care Industry, 53 Temple L.Q. 552
(1979).
“Courts in other states, in construing their own statutes have
held that confidentiality is essential to the proper functioning of
medical review committees.  For example, in Jenkins v. Wu, 102
Ill.2d 468, 82 Ill.Dec. 382, 468 N.E.2d 1162, supra (1984), the
court held that an exception in the Illinois medical review
committee statute which granted a physician access to otherwise
confidential materials in the ‘limited circumstances of a hospital
proceeding to decide upon a physician’s staff privileges or in any
judicial review thereof,’ id., 82 Ill.Dec. at 387, 468 N.Ed.2d at
1167 (citation omitted), did not open the door for discovery of
those same documents in malpractice cases.”
The Baltimore Sun opinion continued (321 Md. at 668, 584 A.2d at 687):
“We think it readily apparent that the statutory protection thereby
afforded by § 14-601(d) is premised upon legislative appreciation
that a high level of confidentiality is necessary for effective
medical peer review.  By protecting these records from public
access in those situations covered by § 14-601(d), the legislature
recognized that a system of effective medical peer review
outweighs the need for complete public disclosu re.”
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B.
Turning to the case at bar, the issue and argumen ts before the Circuit Court
exclusively concerned the meaning and scope of the basic privilege language in § 1-
401(d)(1), which states that “the proceedings, records, and files of a medical review
committee are not discoverab le and are not admissible in evidence in any civil action.”
No party in the Circuit Court raised any issue with regard to the “exceptions” contained
in § 1-401(e), and the trial judge did not consider subsection (e).
The Circuit Court, in its opinion accompanying the order, gave two reasons for
deciding that the “emails, letters, correspondences, and testimony of certain hospital
staff, mostly nurses,” to a medical review committee, were not privileged under the
language of § 1-401(d)(1).  First, the Circuit Court held that the privilege protected
only materials generated by the committee, i.e. in the court’s language, “materials
instituted by an act of a committee.”  Second, the Circuit Court alternatively held that,
even if the privilege were otherwise applicable, “the policy of lawful competition
outweighs the policy of the privilege.”  As previously mentioned, the court, as did
Cardiac Surg ery, relied on Price v. Howard County General Hospital, supra, 950
F.Supp. 141, in support of this position. 
We disagree with both reasons advanced by the Circuit Court.
Nothing in the language of § 1-401(d)(1) supports the position of the Circuit
Court and Cardiac Surgery that only documents generated by the medical review
committee itself are privileged, and that written statements and testimony submitted to
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the committee by nurses, physicians, or other hospital staff, concerning incidents
involving physicians which staff members believe should be investigated or addressed
by the committee, are not privileged.  The critical statutory language is “the
proceedings, records, and files of a medical review committee.”  The words “records”
and “files” are broad.  A letter or testimony by a nurse to a review committee
concerning an incident involving a physician, which is considered by the committee and
may have resulted in a committee investigation or inquiry, would normally become part
of the committee’s “record” or “file” regarding the matter.  The plain language of the
statute is inconsistent with the  Circuit Court’s interpretation.
The Circuit Court’s and Cardiac Surgery’s interpretation of the statute would
require the insertion, after the statutory phrase “records, and files of a medical review
committee,” of the words “generated by the medical review committee.”  This Court,
however, has repeatedly stated that “[w]e will not... ‘judicially insert language [into a
statute] to impose exceptions, limitations, or restrictions not set forth by the
legislature.”  O’Connor v. Baltimore County, 382 Md. 102, 113, 854 A.2d 1191, 1198
(2004), quoting Langston v. Langston, 366 Md. 490, 515, 784 A.2d 1086, 1100 (2001).
See e.g., Lee v. Cline, 384 Md. 245, 257, 863 A.2d 297, 304 (2004); Melton v. State,
379 Md. 471, 477, 842 A.2d 743, 746 (2004) (“[W]e will not add or delete words from
the statute”).  Neither the language nor the purpose of § 1-401(d)(1) supports, the
Circuit Court’s and Cardiac Surgery’s view of the statute.
Furthermore, nothing in the Department of Legislative Reference’s bill file
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concerning Ch. 722 of the Acts of 1976 which originally enacted the privilege, or in
subsequent legislative history associated with amendm ents to the privilege, suggests
that the privilege is limited to documents generated by the medical review committee
itself.  The Department of Legislative Reference’s bill file on Ch. 696 of the Acts of
1997, which broadened the privilege, is quite extensive, consisting of committee
reports, testimony supporting the bill, and other documents.  There is no indication in
any of this material that the privilege attaches only to “acts” of a committee and
excludes statements made to a committee.  On the contrary, the reports and testimony
underscore the breadth, need, and importance of the privilege.
Although most states have statutes creating a medical review committee privilege,
the wording of the statutes varies considerably.  Furthermore, there are only a limited
number of state supreme court decisions dealing with the issue now before us, under
statutes with the same or similar wording to that contained in § 1-401(d).  For a general
review of state statutes and judicial decisions, see Charles David Creek, The Medical
Review Committee Privilege: A Jurisdictional Survey, 67 N.C.L.Rev. 179 (1988);
Susan O. Schentzow and Sylvia Lynn Gillis, Confidentiality and Privilege of Peer
Review Information: More Imagined Than Real, 7 Journal of Law and Health 169
(1993).
One case very much on point is Cruger v. Love, 599 So.2d 111 (Florida 1992).
The section granting a privilege in Florida’s medical review committee statute is
worded like § 1-401(d)(1) of the Maryland statute, and in Cruger, 599 So.2d at 113, the
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party seeking to discover documents argued that they were not privileged because they
were “not generated by the committee . . . .”  In rejecting the argumen t, the Supreme
Court of Florida held as follows (599 So.2d at 113-114):
“The statutes do not define what constitutes records of a
committee or board. Therefore, we must look to the legislative
intent and policy behind the statutes to determine the extent of the
privilege. See White v. Pepsico, Inc., 568 So.2d 886, 889
(Fla.1990); Devin v. City of Hollywood,351 So.2d 1022, 1023
(Fla.1976). We have previously held that ‘[t]he discovery privilege
... was clearly designed to provide that degree of confidentiality
necessary for the full, frank medical peer evaluation which the
legislature sought to encourage.’ Holly v. Auld, 450 So.2d at 220.
Without the privilege, information necessary to the peer review
process could not be obtained. Feldman v. Glucroft, 522 So.2d 798,
801 (Fla.1988). While we recognized in Holly that the discovery
privilege would impinge upon the rights of litigants to obtain
information helpful or even essential to their cases, we assumed
that the legislature balanced that against the benefits offered by
effective self-policing by the medical community. Holly, 450 So.2d
at 220.
“We hold that the privilege provided by sections 766.101(5) and
395.011(9), Florida Statutes, protects any document considered by
the committee or board as part of its decision-making process. The
policy of encouraging full candor in peer review proceedings is
advanced only if all documents considered by the committee or
board during the peer review or credentialing process are protected.
Committee members and those providing information to the
committee must be able to operate without fear of reprisal.
Similarly, it is essential that doctors seeking hospital privileges
disclose all pertinent information to the committee. Physicians who
fear that information provided in an application might someday be
used against them by a third party will be reluctant to fully detail
matters that the committee should consider.” 
See, also, e.g., McGee v. Bruce Hospital System, 312 S.C. 58, 62, 439 S.E.2d 257, 260
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(1993) (“We interpret the legislative intent to protect not only documents generated by
the committee, but also documents acquired by the committee in the course of its
proceedings”).  
The above-quoted holdings could also be applied to § 1-401(d)(1) of the
Maryland statute.  In light of the wording and purpose of § 1-401(d)(1), the basic
coverage of the privilege statute is not limited to documents generated by a medical
review committee itself.  
The Circuit Court’s alternative position, that the Maryland policy underlying an
“unfair competition” tort case “outweighs the policy of the privilege,” and the court’s
reliance on Price v. Howard County General Hospital, supra, 950 F.Supp. 141, were
also clearly in error.  The Price case was an action under the federal antitrust statutes,
where “federal,” not Maryland, “law of privileges [was] applicable,” and thus “the
Maryland medical peer review privilege [was] not controlling.”  Price, 950 F.Supp. at
142-143.  As a matter of federal law, the policy of “the federal antitrust laws” was held
to “outweigh the policies underlying the state privilege.”  Price, 950 F.Supp. at 143.
The present case, on the other hand, involves exclusively Maryland law and
Maryland policy.  The “weighing” was done by the Maryland General Assembly, which
decided that, where the privilege was applicable, it outweighed the need for the
privileged material “in any civil action.”   § 1-401(d)(1).  See Baltimore Sun v.
University of Maryland Medical System, supra, 321 Md. at 668, 504 A.2d at 687
(“[T]he legislature recognized that a system of effective medical peer review outweighs
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the need for . . . disclosure”).
The expansion of the privilege, by Ch. 696 of the Acts of 1997, is particularly
instructive in this regard.  As earlier discussed, prior to 1997 the privilege only applied
in a “civil action arising out of matters that are being reviewed and evaluated by the
medical review comm ittee.”  The 1997 change, however, extended the privilege to “any
civil action.”  Certainly, a Maryland tort action based on alleged unfair competition and
interference with economic relations falls within the statutory phrase “any civil action.”
The Floor Report by the House Environmental Matters Committee on House Bill 775
of the 1997 General Assembly session, which bill became Ch. 696, stated as follows
(emphasis added): 
“Under current law, the proceedings, records, and files of a
medical review committee are not admissible in any civil action
that arise out of matters that are being reviewed and evaluated by
the medical review committee.  HB 775 would expand coverage to
all types of civil litigation.  This is important because a hospital
can get subpoenas in divorce actions, antitrust actions, car
accidents, health insurance disputes, etc.  This can make important
documents public records and drag doctors into collateral litigation
as witnesses.”  
There is little doubt that the General Assemb ly intended the privilege to be applicable
in Maryland tort actions based on alleged unfair competition.  
In sum, the grounds for disallowing the privilege advanced by Cardiac Surgery
in the trial court, and accepted by the trial court, are erroneous and do not support the
trial court’s order.  
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C.
Cardiac Surg ery, for the first time in its brief in this Court, relies on the
exception to the privilege set forth in § 1-401(e)(2), which provides (emphasis added):
“Subsection (d)(1) of this section does not apply to:
* * *
(2) Any record or document that is considered by the medical
review committee and that otherwise would be subject to discovery
and introduction into evidence in a civil trial.”
Cardiac Surg ery, in this Court, contends that § 1-401(e)(2) supports its argument that
only materials generated by a medical review committee fall within the privilege set
forth in § 1-401(d)(1).
As indicated above, no issue concerning § 1-401(e)(2) was raised in the trial
court or considered by the trial judge.  Furthermore, although the “privilege log” is
contained in the record extract, none of the disputed documents themselves are before
us.  Accordingly, it would be difficult for this Court to finally decide anything
regarding the specific disputed documents, other than our holdings, as set forth above,
that the two grounds relied on by the trial court are erroneous and, therefore, do not
support the trial court’s order.  Nevertheless, “to guide the trial court” and “to avoid
the expense and delay of another appeal” (Rule 8-131(a)), we shall comment on the
applicability of § 1-401(e)(2).  
This Court in Baltimore Sun v. University of Maryland Medical System, supra,
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321 Md. 659, 584 A.2d 683, previously commented on the exception now set forth in
§ 1-401(e)(2), and then codified as § 14-601(e)(2).  Chief Judge Murphy for the Court
there stated (321 Md. at 665, 584 A.2d at 686):
“The subsequent recodification of these provisions as § 14-
601(d) and (e)(1) and (2) was accomplished by ch. 8 of the Acts of
1981.  According to the ‘Revisor’s Note,’ the recodification was
without substantive  change from former Article 43, § 134A.3
_____________________
 3
Somewhat cryptically, the Revisor’s Note appended to § 14-
601‘calls to the attention of the General Assemb ly that
present Art. 43, § 134A(d) states in its first sentence that
certain documents are privileged from discovery and
admission into evidence and then in its third sentence
provides for an exception that seemingly is as broad as the
privilege.  The revised language in this section closely
follows the present law.  However, the Commission believes
that present Art. 43, § 134A(d), and, in turn, this section,
may not state the intent of the General Assembly.’”
There appears to be no additional legislative history, either in 1976 or 1981 or later,
which casts any light on the General Assembly’s intent concerning this exception.
As pointed out by the Revisor in 1981, a broad literal reading of the exception
would do away with the privilege.  Such an interpretation would be unreasonable and
would violate the principle that statutes should not, if possible, be given an
unreasonable interpretation.
The only indication of § 1-401(e)(2)’s meaning is found in judicial opinions from
other states.  Similar language has been interpreted to mean that, although a party to a
lawsuit cannot get the documents from the hospital of which the review committee is
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a part, nevertheless if such documents are otherwise properly available from other
sources and otherwise admissible, the party may obtain them from such other sources.
The fact that they are also in a medical review committee’s file does not preclude
obtaining them from other sources.  See, e.g., Sun Health Corp. v. Myers, 205 Ariz.
315, 320, 70 P.3d 444, 449 (2003) (“The plaintiff can seek information outside the
review process and information from the original sources including court records,”
etc.);  Yuma Regional Medical Center v. Superior Court, 175 Ariz. 72, 76, 852 P.2d
1256, 1260 (1993) (“As plaintiffs note, the peer review privilege does not protect
information that originated outside the peer review process and that is discoverab le
from alternative sources”); Munroe Regional Medical Center v. Rountree, 721 So.2d
1220, 1223 (Fla. App. 1998) (“[I]f available from original sources other than the
committee, such information is discoverable”); Hollowell v. Jove, 247 Ga. 678, 682,
279 S.Ed.2d 430, 434 (1981) (“We must note, however, that ‘information, documents,
or records otherwise available from original sources are not to be construed as immune
from discovery or use in any such civil action merely because they were presented
during proceedings of such committee’”); Virmani v. Presbyterian Health Services
Corp., 350 N.C. 449, 468, 515 S.E.2d 675, 688 (1999) (“‘These provisions mean that
information, in whatever form available, from original sources other than the medical
review committee is not immune from discovery or use at trial merely because it was
presented during medical review committee proceedings,’” quoting Shelton v.
Morehead Memorial Hospital, 318 N.C. 76, 83, 347 S.E.2d 824, 829 (1986)); Claypool
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6
House Bill 1035 of the 1976 General Assembly session became Ch. 722 of the Acts of 1976
which initially created medical review committees, provided that material in committee records and
files was privileged, and granted immunity from damage suits for committees, members thereof, and
persons or organizations providing information to committees.  As originally introduced, the
language of the exception, which later became § 1-401(e)(2), more clearly reflected the position of
the above-cited out-of-state cases as to the exception’s meaning.  During House Bill 1035's journey
through the General Assembly, the subsections relating to privilege and immunity from suit were
entirely  re-written.  The final wording of the exception is essentially the same as the present wording
of § 1-401(e)(2).  While there is a Department of Legislative Reference file on House Bill 1035, it
contains very little material and fails to explain why the language of the exception was changed.
Whether the change was intended to be simply stylistic or, on the other hand, was intended to be
substantive, is a mystery.  Absent any indication of legislative intent to the contrary, we shall, as
indicated above, assume that the change was simply stylistic.
v. Mladineo, 724 So.2d 373, 383 (Miss. 1998) (“The . . . statute . . . provided that the
privilege did not extend to information that originated outside the peer review
process”); Moretti v. Lowe, 592 A.2d 855, 858 (R.I. 1991) (The statute “does not render
immune information otherwise available from original sources even if the information
was presented at a peer-review committee meeting”); McGee v. Bruce Hospital System,
supra, 312 S.C. at 62-63, 439 S.E.2d at 260 (“Hence, the plaintiff seeking discovery
cannot obtain documents which are available from the original source directly from the
hospital committee, but may seek them from alternative sources”); Anderson v. Breda,
103 Wash.2d 901, 906, 700 P.2d 737, 741 (1985) (“Petitioners are not deprived of the
opportunity to develop [information] through sources other than the records of the
committee”).
Absent any additional discovery of legislative intent regarding § 1-401(e)(2), or
subsequent legislative clarification, the Circuit Court on remand should apply the
exception in accordance with the above principles.6  Under those principles, it would
seem that documents from the records or files of the medical review committee, which
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are in St. Joseph’s possession, would not be discoverable.  Whether documents in
Cardiac Surgery’s possession fall within the exception must be determined by the trial
circuit.
Our decision in this case does not go beyond the holding that the two grounds
relied upon by the trial court, for deciding that the privilege was inapplicable, are not
valid.  The trial court on remand will have to again resolve the discovery disputes in
accordance with the principles set forth in this opinion.
MOT IO N  
T O  
D I S M I S S  
DENIE D .
JUDGMENT OF THE CIRCUIT COURT FOR
BALTIMORE COUNTY REVERSED, AND
CASE REMANDED TO THE CIRCU IT
COURT FOR FURTHER PROCEEDINGS
CONSISTENT 
WITH 
THIS 
OPINION.
C O S T S  
T O  
B E  
P A I D  
B Y  
T H E
RESPONDEN T 
CARDIAC 
SURGERY
ASSOCIATES, P.A.