Title: In the Matter of Miguel M.

State: new-york

Issuer: New York Appellate Court

Document:

=================================================================
This opinion is uncorrected and subject to revision before
publication in the New York Reports.
-----------------------------------------------------------------
No. 76  
In the Matter of Miguel M. 
(Anonymous), &c.,
            Appellant;
Charles Barron, &c.,
            Respondent.
Scott M. Wells, for appellant.
Tahirih M. Sadrieh, for respondent.
SMITH, J.:
We hold that the Privacy Rule adopted by the federal
government pursuant to the Health Insurance Portability and
Accountability Act (HIPAA) prohibits the disclosure of a
patient's medical records to a State agency that requests them
for use in a proceeding to compel the patient to accept mental
health treatment, where the patient has neither authorized the
- 1 -
- 2 -
No. 76
disclosure nor received notice of the agency's request for the
records.
I
Dr. Charles Barron, as designee of the New York City
Department of Health and Mental Hygiene, applied for an order
under Mental Hygiene Law § 9.60 requiring "assisted outpatient
treatment" (AOT) for Miguel M.  The petition alleged that Miguel
was suffering from a mental illness; that he was unlikely to
survive safely in the community without supervision; that he had
a history of failing to comply with treatment; that he was
unlikely to participate in necessary treatment voluntarily; and
that he needed, and would benefit from, AOT to prevent a relapse
or deterioration of his mental status, which would be likely to
result in serious harm to Miguel or to others.
At the hearing on the petition, Barron offered in
evidence records from two hospitals relating to three occasions
on which Miguel was hospitalized.  A witness called by Barron
testified that the hospitals had furnished the records in
response to a request -- a request made, it is clear from the
record, without notice to Miguel.  The witness acknowledged that
Miguel had not authorized the release of the records, and that no
court order for their disclosure had been sought or obtained.
The records were received in evidence over Miguel's
objection, and Barron's witness described their contents.  After
the hearing, Supreme Court directed that Miguel "receive and
- 2 -
- 3 -
No. 76
accept assisted outpatient treatment" for a period of six months. 
The Appellate Division affirmed.  We granted leave to appeal, and
now reverse.
II
The six-month duration of Supreme Court's order expired
before the Appellate Division decided this case, and the
immediate controversy is therefore moot.  Neither party
challenges, however, the Appellate Division's conclusion that the
case presents a novel and substantial issue that is likely to
recur and likely to evade review, and that therefore the
exception to the rule against deciding moot disputes applies here
(see Matter of Hearst Corp. v Clyne, 50 NY2d 707, 714-715
[1980]).  We agree, and proceed to the merits.
Mental Hygiene Law § 9.60, known as "Kendra's Law," was
enacted in 1999.  It is named for Kendra Webdale, who was killed
by a mentally ill man who pushed her off a subway platform.  It
says that, on a proper showing, a mentally ill person whose lack
of compliance with treatment has, twice within the last 36
months, caused him or her to be hospitalized may be the subject
of AOT pursuant to a plan stated in a court order (see Mental
Hygiene Law § 9.60 [c], [j] [2]).  Public officials identified as
"directors of community services" are given the duty of enforcing
Kendra's Law (Mental Hygiene Law § 9.47 [b]), and a petition to
require AOT may be filed by a director of community services or
his or her designee (Mental Hygiene Law § 9.60 [e] [1] [vii]). 
- 3 -
- 4 -
No. 76
Mental Hygiene Law § 33.13 (c) (12) permits disclosure of medical
records to a director of community services who requests it in
the exercise of his or her duties.  Thus, the disclosure of a
patient's medical records for purposes of an AOT proceeding is
permitted by State law, unless the applicable State law is
preempted.  Miguel argues that it is.
Miguel says that preemption is found in HIPAA (Pub L No
104-191, 110 US Stat 1936, codified in various titles of the
United States Code) and the Privacy Rule (45 CFR Titles 160 and
164) promulgated by the United States Department of Health and
Human Services under authority granted by HIPAA § 264 (c) (1)
(see note to 42 USC § 1320d-2).  The Privacy Rule prohibits
disclosure of an identifiable patient's health information
without the patient's authorization, subject to certain
exceptions (45 CFR § 164.508 [a] [1]).  HIPAA § 264 (c) (2) (see
note to 42 USC § 1320d-2) and the Privacy Rule (45 CFR § 160.203
[b]) say that contrary state laws are preempted unless they offer
privacy protections that are "more stringent" than those of the
federal law; New York does not offer any more stringent
protection that is relevant here.  The preemption issue thus
comes down to whether the disclosure of Miguel's medical records
was permitted by one of the exceptions to the Privacy Rule.
Barron relies on two exceptions, those permitting
disclosure for purposes of "public health" and "treatment."  It
is possible to read the language of both exceptions as covering
- 4 -
- 5 -
No. 76
the disclosure now at issue, but in both cases the reading is
strained.  Considering the apparent purposes of these two
exceptions, we conclude that neither fits these facts.
The public health exception permits disclosure of
protected information to:
"A public health authority that is authorized
by law to collect or receive such information
for the purpose of preventing or controlling
disease, injury, or disability, including,
but not limited to, the reporting of disease,
injury, vital events such as birth or death,
and the conduct of public health
surveillance, public health investigations,
and public health interventions" 
(45 CFR § 164.512 [b] [1] [i]).
Barron reasons that disclosure of a mentally ill
person's hospital records for purposes of requiring that person
to accept AOT protects the public health, because mentally ill
people might kill or injure other people -- like Kendra Webdale -
- who, of course, are members of the public.  Thus Barron, a
person designated to enforce Kendra's Law, would be a "public
health authority," collecting information for the "purpose of
preventing . . . injury," and his action to require AOT in
Miguel's case could be called a public health intervention.  We
are not convinced, however, that the authors of the Privacy Rule
meant "public health" in this literal, but counterintuitive,
sense.
The apparent purpose of the public health exception is
to facilitate government activities that protect large numbers of
- 5 -
- 6 -
No. 76
people from epidemics, environmental hazards, and the like, or
that advance public health by accumulating valuable statistical
information.  To disclose private information about particular
people, for the purpose of preventing those people from harming
themselves or others, effects a very substantial invasion of
privacy without the sort of generalized public benefit that would
come from, for example, tracing the course of an infectious
disease.  The disclosure to Barron of Miguel's hospital records
was not within the scope of the public health exception.
The treatment exception permits disclosure of protected
health information "for treatment activities of a health care
provider" (45 CFR § 164.506 [c] [2]).  "Treatment" is defined as:
"the provision, coordination, or management
of health care and related services by one or
more health care providers, including the
coordination or management of health care by
a health care provider with a third party;
consultation between health care providers
relating to a patient; or the referral of a
patient for health care from one health care
provider to another"
(45 CFR § 164.501).
Again, Barron's argument is literalistic: AOT --
assisted outpatient treatment -- is literally "treatment" -- "the
provision . . . of health care . . . by one or more health care
providers."  But the thrust of the treatment exception is to
facilitate the sharing of information among health care providers
working together.  We see no indication that the authors of the
regulation meant to facilitate "treatment" administered by a
- 6 -
- 7 -
No. 76
volunteer "provider" over the patient's objection.  Disclosure
for that purpose is a more serious invasion of privacy than, for
example, the transmission of medical records from a patient's
primary care physician to a specialist -- the sort of activity
for which the treatment exception seems primarily designed.  The
treatment exception is inapplicable here.
We find support for our conclusion that the two
exceptions Barron relies on are inapposite in the existence of
other exceptions that Barron might have invoked but did not.  The
Privacy Rule authorizes disclosure of health information, subject
to certain conditions, "in the course of any judicial or
administrative proceeding," in response to either "an order of a
court or administrative tribunal" (45 CFR § 164.512 [e] [1] [i])
or "a subpoena, discovery request, or other lawful process" (45
CFR § 164.512 [e] [1] [ii]).  Thus, Barron could have pursued
Miguel's records either by seeking a court order or by serving a
subpoena.  To do so in compliance with the Privacy Rule, however,
Barron would have had to give notice to Miguel of his request for
the records.  He could not, absent extraordinary circumstances,
have obtained a court order requiring disclosure without giving
such notice.  And the Privacy Rule's exception for subpoenas and
the like is conditioned on "satisfactory assurance" from the
person seeking the information to the entity providing it either
"that reasonable efforts have been made . . . to ensure that the
individual who is the subject of the protected health information
. . . has been given notice of the request" (45 CFR § 164.512 [e]
-  7 -
- 8 -
No. 76
[1] [ii] [A]), or that an order protecting the confidentiality of
the information has been sought (45 CFR § 164.512 [e] [1] [ii]
[B]).  In a case, like this one, to which the patient is a party,
a request for a protective order would require notice to the
patient.
We can see no reason, and Barron has suggested none,
why notice should not have been given here.  It may well be, in
this case as in many others, that no valid ground for withholding
the records exists; courts ruling on disclosure issues will
surely be conscious, as we are, of the strong public interest in
seeing that mentally ill people who might otherwise be dangerous
receive necessary treatment.  But it seems only fair, and no
great burden on the public agencies charged with enforcing
Kendra's Law, to give patients a chance to object before the
records are delivered.
We emphasize that it is far from our purpose to make
the enforcement of Kendra's Law difficult.  It may often be
possible to avoid all disclosure problems by getting the patient
to authorize the disclosure in advance; surely many mentally ill
people will, while they are under proper care, recognize that
disclosure is very much in their own interest.  When there is no
advance authorization, patients who are given notice that their
records are being sought often may not object; when they do
object, their objections may often be overruled.  We hold only
that unauthorized disclosure without notice is, under
circumstances like those present here, inconsistent with the
Privacy Rule.
- 8 -
- 9 -
No. 76
III
Barron argues in the alternative that, even if the
disclosure of the records to him was unlawful -- as we have held
it was -- Supreme Court did not err by admitting the records into
evidence at the AOT hearing.  HIPAA, as Barron points out,
contains its own remedies for violations: civil penalties (HIPAA
§ 262 [a], 42 USC § 1320d-5) and, for the knowing and wrongful
disclosure of individually identifiable health information, fines
and imprisonment (HIPAA § 262 [a], 42 USC § 1320d-6).  Neither
exclusion of the records from evidence nor suppression of
evidence obtained by use of the records is among the remedies
listed.  Barron cites decisions from other states holding that
evidence obtained as a result of a HIPAA violation need not be
suppressed in a criminal case (State v Carter, 23 So 3d 798, 801
[Fla App 2009]; State v Yenzer, 40 Kan App 2d 710, 712-713, 195 P
3d 271, 272-273 [2008]; State v Straehler, 307 Wis 2d 360, 745 NW
2d 431 [Wis App 2007]).
We assume it is correct that, in a criminal case, a
HIPAA or Privacy Rule violation does not always require the
suppression of evidence.  Indeed, we have held that suppression
is not required in such a case where evidence was obtained as a
result of a violation of New York's physician-patient privilege
(People v Greene, 9 NY3d 277 [2007]).  But this case is
different.  It is one thing to allow the use of evidence
resulting from an improper disclosure of information in medical
records to prove that a patient has committed a crime; it is
another to use the records themselves, or their contents, in a
- 9 -
- 10 -
No. 76
proceeding to subject to unwanted medical treatment a patient who
is not accused of any wrongdoing.  Using the records in that way
directly impairs, without adequate justification, the interest 
protected by HIPAA and the Privacy Rule: the interest in keeping
one's own medical condition private.  We therefore hold that
medical records obtained in violation of HIPAA or the Privacy
Rule, and the information contained in those records, are not
admissible in a proceeding to compel AOT.
Accordingly, the order of the Appellate Division should
be reversed, with costs, and the case remitted to Supreme Court
for further proceedings in accordance with this opinion. 
*   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *
Order reversed, with costs, and matter remitted to Supreme Court,
Queens County, for further proceedings in accordance with the
opinion herein.  Opinion by Judge Smith.  Chief Judge Lippman and
Judges Ciparick, Graffeo, Read, Pigott and Jones concur.
Decided May 10, 2011
- 10 -