Opinion ID: 1060432
Heading Depth: 3
Heading Rank: 2

Heading: inducement to breach express and implied

Text: CONTRACTS OF CONFIDENTIALITY The plaintiff next alleges that her physician was bound by express and implied contracts to keep her medical information confidential and that the Richardson Firm, in its efforts to obtain this information, induced him to breach these contracts of confidentiality. More specifically, the plaintiff alleges that the Richardson Firm is liable for inducement to breach contracts of confidentiality by requesting medical records through the use of defective subpoenas and by initiating private conversations with her physician and other health care providers outside a formal deposition. Tennessee recognizes both a statutory and common law action for inducement to breach a contract, see Tenn. Code Ann. § 47-50-109 (2001); Polk & Sullivan, Inc. v. United Cities Gas Co., 783 S.W.2d 538, 543 (Tenn. 1989), and both forms of the action protect “contracts implied in fact, as well as formal, expressed contracts,” Mefford v. City of Dupontonia, 49 Tenn. App. 349, 355, 354 S.W.2d 823, 826 (1961). Importantly, the elements for both forms of the action are identical, except that a plaintiff asserting a common law action may recover punitive damages, instead of the treble damages mandated by the statute. See Buddy Lee Attractions, Inc. v. William Morris Agency, Inc., 13 S.W.3d 343, 360-61 (Tenn. Ct. App. 1999). In order to recover on a theory of inducement to breach a contract, a plaintiff must allege and prove seven elements: (1) that a legal contract existed; (2) that the defendant was aware of the contract; (3) that the defendant intended to induce a breach of that contract; (4) that the defendant acted with malice; (5) that a breach of the contract occurred; (6) that the breach was a proximate result of the defendant’s conduct; and (7) that the breach injured -17- the plaintiff. See Quality Auto Parts Co. v. Bluff City Buick Co., 876 S.W.2d 818, 822 (Tenn. 1994); Baker v. Hooper, 50 S.W.3d 463, 468 (Tenn. Ct. App. 2001). Inducement to Breach an Express Contract of Confidentiality As to her allegations of inducement to breach an express contract of confidentiality, the plaintiff alleges that an express contract of confidentiality was created when the plaintiff’s physician required her to execute a written waiver of confidentiality before sending her medical records to her own attorney. The parties raise substantial issues of Allstate’s awareness of this alleged contract and of its intent to induce its breach. Our review of the complaint, however, raises an even more fundamental issue: whether the allegations of the complaint plead an express contract of confidentiality or merely a physician’s gratuitous promise of confidentiality. As claimed in the complaint, the alleged express contract of confidentiality was not part of the original contract of treatment for compensation. Rather, the physician requested the written authorization that forms the basis of this alleged contract only after the plaintiff had been treated and later retained counsel. As such, an issue arises whether this alleged agreement is a new agreement or merely an addition or modification of the existing treatment contract between the plaintiff and her physician. Drawing the inference in favor of the plaintiff, as the law requires us to do when reviewing a motion to dismiss, see McClenahan v. Cooley, 806 S.W.2d 767, 769 (Tenn. 1991), we will presume that this new agreement is merely a modification of the earlier contract. The law in Tennessee is clear that the “modification of an existing agreement which imposes new obligations on one of the parties is unenforceable for lack of consideration unless it also imposes a new obligation on the other party.” Dunlop Tire & Rubber Corp. v. Service Merch. Co., 667 S.W.2d 754, 759 (Tenn. Ct. App. 1983); see also Boyd v. McCarty, 142 Tenn. 670, 676, 222 S.W. 528, 530-31 (1920). Indeed, “[p]erforming what was already promised in the original contract is not consideration to support a second contract.” Dunlop Tire & Rubber Corp., 667 S.W.2d at 759 (citing American Fruit Growers, Inc. v. Hawkinson, 21 Tenn. App. 127, 134, 106 S.W.2d 564, 568 (1937)). As such, to state a claim showing the existence of an enforceable contract in this regard, the complaint must allege facts showing that the plaintiff offered additional consideration to support the physician’s new and express promise to keep her records confidential. However, upon our review of the complaint in this case, we do not find any facts alleging that this promise of confidentiality was supported by additional consideration, nor do we find that the facts as alleged lead to a reasonable inference that the promise was supported by consideration. For example, the complaint does not allege that the plaintiff, in exchange for this new express promise of confidentiality, agreed to undertake additional obligations for the benefit of her physician or that she agreed to forbear from doing anything that she previously had a lawful right to do. See Brown Oil Co. v. Johnson, 689 S.W.2d 149, 151 (Tenn. 1985) (“It is well-settled that consideration exists when the promisee does something that it is under no legal obligation to do or refrains from doing something which it has a legal right to do.”). Moreover, the complaint does not allege, nor are we able to infer, that the parties originally intended for the express promise of confidentiality to be part -18- of the original contract of treatment for compensation, but that it was omitted from any express contract by some oversight. Cf. Wright v. Fischer, 24 Tenn. App. 650, 658, 148 S.W.2d 49, 53 (1940). Although the Court of Appeals held that the plaintiff sufficiently pleaded the existence of an express contract, we respectfully disagree. We are required to “liberally construe the complaint in favor of the plaintiff when considering a motion to dismiss for failure to state a claim,” see, e.g., White, 33 S.W.3d at 718 (citation omitted), but we are not permitted to “create a claim that the pleader does not spell out in his complaint,” Donaldson, 557 S.W.2d at 62; see also Rampy v. ICI Acrylics, Inc., 898 S.W.2d 196, 198 (Tenn. Ct. App. 1994) (“It is inappropriate for the court to create a claim where none exists.”). As such, the mere legal conclusion that a contract exists will not be sufficient to withstand a motion to dismiss, unless factual allegations support that conclusion directly or by necessary inference. See White, 33 S.W.3d at 718 (stating that “allegations of pure legal conclusions will not sustain a complaint”). Accordingly, because the complaint does not allege facts showing the existence of an enforceable express contract supported by adequate and sufficient consideration, we hold that the plaintiff has not stated a claim against Allstate for inducement to breach an express contract of confidentiality. Inducement to Breach an Implied Contract of Confidentiality As to the plaintiff’s allegations of inducement to breach an implied contract of confidentiality, her complaint alleges that such a contract was created when she agreed to pay money in return for medical treatment. She further alleges that this implied contract arose from the specific understanding and actions of the parties that her medical information would remain confidential. Accordingly, we must examine the complaint’s allegations to determine whether facts have been sufficiently plead to support the various elements of this tort. a. The Existence of an Implied Contract of Confidentiality A contract implied in fact is one that “arise[s] under circumstances which show mutual intent or assent to contract.” Angus v. City of Jackson, 968 S.W.2d 804, 808 (Tenn. Ct. App. 1997). Such a contract or agreement “may result as a legal inference from the facts and circumstances of the case,” Paschall’s, Inc. v. Dozier, 219 Tenn. 45, 53, 407 S.W.2d 150, 154 (1966), but to be enforceable, the implied contract must nevertheless be supported by mutual assent, consideration, and lawful purpose. See Johnson v. Central Nat’l Ins. Co., 210 Tenn. 24, 34-35, 356 S.W.2d 277, 281 (1962) (recognizing that an implied contract “must result from a meeting of the minds of the parties in mutual assent to the terms, [and] must be based upon a sufficient consideration, free from fraud or undue influence, not against public policy and sufficiently definite to be enforced”); Lay v. Fairfield Dev., 929 S.W.2d 352, 356 (Tenn. Ct. App. 1996) (same). Although we have yet to decide a case where an implied contract of confidentiality arose between a physician and a patient, we have recognized that such a possibility exists when a patient compensates a physician in return for medical treatment. See Quarles v. Sutherland, 215 Tenn. 651, -19- 657, 389 S.W.2d 249, 252 (1965). Since our decision in Quarles, however, the General Assembly has enacted several statutes that expressly require a physician and others to keep a patient’s medical records and identifying information confidential. See Tenn. Code Ann. §§ 63-2-101(b)(1) (1997); 68-11-1502 (2001); 68-11-1503 (2001). Through the enactment of these statutes, patients and physicians now clearly expect that the physician will keep the patient’s information confidential, and this expectation arises at the time that the patient seeks treatment. As one of the leading cases recognizing implied covenants of confidentiality in this context has acknowledged, Any time a doctor undertakes the treatment of a patient, and the consensual relationship of physician and patient is established, two jural obligations (of significance here) are simultaneously assumed by the doctor. Doctor and patient enter into a simple contract, the patient hoping that he will be cured and the doctor optimistically assuming that he will be compensated. As an implied condition of that contract, this Court is of the opinion that the doctor warrants that any confidential information gained through the relationship will not be released without the patient’s permission. . . . Consequently, when a doctor breaches his duty of secrecy, he is in violation of part of his obligations under the contract. Hammonds v. Aetna Cas. & Sur. Co., 243 F. Supp. 793, 801 (N.D. Ohio 1965). As such, we now expressly hold that an implied covenant of confidentiality can arise from the original contract of treatment for payment, and we find that the plaintiff’s complaint here has adequately alleged the existence of an implied covenant of confidentiality. b. Breach of Implied Covenant of Confidentiality Based Upon the Physician’s Response to Subpoenas Having found the existence of an implied covenant of confidentiality, we must next examine whether the complaint has alleged a breach of this implied covenant. Initially, it is clear that whatever the terms of this implied covenant of confidentiality may be, a physician cannot withhold such information in the face of a subpoena or other request cloaked with the authority of the court. Undoubtedly, any such contract would be contrary to public policy as expressed in the rules governing pre-trial discovery and in the relevant medical confidentiality statutes.10 Nevertheless, the plaintiff would have us declare that a physician does have a duty to keep a patient’s information confidential in the face of a technically defective subpoena. We agree that the subpoenas issued by the Richardson Firm without the plaintiff’s agreement did not strictly comply with the requirements of Rule of Civil Procedure 45.07. However, we do not agree that a physician is under a duty to discover technical defects in a subpoena, or to submit a subpoena for 10 See Tenn. Code Ann. § 63-2-101(b)(1) (1997); Tenn. Code Ann. § 68-11-304(a)(1) (2001); Tenn. Code Ann. § 68-11-1505 (2001). These statutes, of course, do nothing to change the common law of Tennessee, which does not recognize the existence of a testimonial privilege between a physician and patient. See Quarles, 215 Tenn. at 657, 389 S.W.2d at 252. -20- legal review and evaluation, before releasing a patient’s medical records. Instead, the law can only require a physician responding to such request to act in good faith and with a subjective belief as to the validity of that request. Consequently, unless a plaintiff can show that a physician acted in bad faith or with actual knowledge of the subpoena’s invalidity, no breach of an implied covenant of confidentiality can occur in this context.11 Using this standard as our guide, we find that the plaintiff has not alleged sufficient facts showing that her physician actually breached his implied covenant of confidentiality by releasing records pursuant to a technically defective subpoena. For example, we find no allegation that the physician acted in bad faith in sending the plaintiff’s medical records to the Richardson Firm or that he was actually aware that the subpoenas did not meet the technical requirements of the law. Without these averments, therefore, we must hold that the plaintiff has not stated a claim that the Richardson Firm, in requesting medical records through subpoena, induced her physician to breach his implied covenant of confidentiality. c. Breach of Implied Covenant of Confidentiality Based upon the Physician’s Private Conversations with Opposing Counsel A much different case is presented, however, with respect to whether the physician breached his implied covenant of confidentiality by informally speaking to members of the Richardson Firm about the plaintiff’s medical information. While the understanding of the parties giving rise to the implied covenant of confidentiality permits a physician to disclose information pursuant to subpoena or court order, this understanding does not include permission to divulge this information informally without the patient’s consent.12 Therefore, absent circumstances giving rise to a duty to warn identifiable third persons against foreseeable risks emanating from a patient’s illness, see Bradshaw v. Daniel, 854 S.W.2d 865, 872 (Tenn. 1993), we hold that a physician breaches his or her implied covenant of confidentiality by divulging medical information, without the patient’s consent, through informal conversations with others. Accordingly, we find that the complaint in this case alleges sufficient facts showing that the physician breached his implied covenant of confidentiality by informally speaking to the Richardson Firm about the plaintiff’s condition without her consent.13 11 This is not to say that a party is without any recourse against a technically defective subpoena seeking medical records or that parties are fre e to obtain d iscoverable inform ation b y any me ans possible without regard to proper processes or procedures. Rather, we conclude that the authority given to trial courts by the R ules of C ivil Pro cedure to regulate the discovery process is adequate to deal with such technical deficiencies in the me thod of discovery. See Tenn. R. Civ. P. 26.03; 37.01(4). 12 The physician’s statutory duty of confidentiality is subject to several limited exceptions, see Tenn. Code Ann. §§ 63-2-101(b)(1); 68-11-1503, but no exception permits disclosure of medical information in private conversations without the patient’s consent. As such, we are not inclined to find that patients or physicians typically expect that the physician’s imp lied co venant of confidentiality contains an “info rmal interview” exception. 13 Allstate argues tha t Alessio v. Crook, 633 S.W.2d 770, 780 (Tenn. Ct. App. 1982), permits informal interviews of physicians without the patient’s consent, and as such, attorneys cannot be guilty of inducing a breach of (continued...) -21- d. Damages Resulting from the Physician’s Private Conversations with Opposing Counsel Having found sufficient allegations concerning the existence and breach of an implied contract of confidentiality, and presuming, but not deciding, that facts are pled showing the elements of knowledge, intent, and malice, we must examine whether the plaintiff has alleged facts showing that she has suffered damage from this breach. The plaintiff claims that as a result of these informal conversations between the Richardson Firm and her physician, she has suffered a “strategic loss” in the litigation. More specifically, she alleges that the Richardson Firm “was free to explore Dr. Holcomb’s thoughts with impunity until he revealed something favorable to them, which could then be inquired about in a deposition unencumbered with a lot of unfavorable testimony.” No other allegations of injury arising out of these informal conversations are present.14 No case in Tennessee has previously recognized that, as a matter of law, a party may claim injury based on a “strategic loss” in pre-trial litigation, and we decline to recognize such a possibility here. Quite simply, if the plaintiff was concerned that testimony unfavorable to the defendant was not adequately disclosed in the deposition of her physician, then her remedy was to prepare an examination of the physician herself, thereby ensuring a complete record for trial. Because the complaint alleges no legally cognizable injury resulting from these informal conversations with the plaintiff’s physician, we must find that she has not stated a claim that the Richardson Firm, by initiating informal and private conversations with her physician, induced him to breach his implied covenant of confidentiality. C. INDUCEMENT TO BREACH A CONFIDENTIAL RELATIONSHIP The plaintiff next alleges that the Richardson Firm, by obtaining her medical information with defective subpoenas and through private conversations with her physician, induced him to breach his confidential relationship with her. Because confidential relationships in Tennessee can assume a variety of forms, a unifying principle connecting all such relationships is difficult to establish. Nevertheless, prior cases make it clear that a confidential relationship is not one merely exhibiting mutual trust and confidence. Rather, the relationship is more accurately described as one 13 (...continued) an implied covenant of confidentiality by merely requesting such an interview. We d isagree. Although Alessio does contain dicta to support Allstate’s argument, that case was decided prior to the enactment of Tennessee Code Annotated section 63-2-101 and the Patient’s Privacy Protection Act. After the enactment of these statutes, patients and physicians now generally expect that the phys ician will keep the patient’s med ical inform ation confidential, sub ject to a duty to disclose impo sed b y law. Co nsequently, any stateme nts in Alessio that permit counsel to informally interview a physician without the patient’s consent no longer accurately reflec t the law in this area. 14 The plaintiff does allege elsewhere that she suffered “great embarrassment, anger and stress over the knowledge that the details of her most intimate revelations to all of her many healthcare professionals have been made pub lic by the conduct of the Richardson Firm.” However, these claims precede her allegations that the Richardson Firm induced a breach of her physician’s implied covenant of confidentiality by initiating private conversations, and they seem to relate only to her claim s of inducement based upon the defective subpo enas. -22- in which “‘confidence is placed by one in the other and the recipient of that confidence is the dominant personality, with ability, because of that confidence, to influence and exercise dominion and control over the weaker or dominated party.’” Mitchell v. Smith, 779 S.W.2d 384, 389 (Tenn. Ct. App. 1989) (quoting Iacometti v. Frassinelli, 494 S.W.2d 496, 499 (Tenn. Ct. App. 1973)). This Court has long recognized that an abuse or breach of a confidential relationship to gain a benefit or advantage will give rise to an action for damages. See Leake v. Gray, Shillinglaw & Co., 189 Tenn. 574, 592, 226 S.W.2d 298, 305 (1949). As we stated in Turner v. Leathers, 191 Tenn. 292, 298, 232 S.W.2d 269, 271 (1950), Whenever two persons stand in such a relation that, while it continues, confidence is necessarily reposed by one, and the influence which naturally grows out of that confidence is possessed by the other, and this confidence is abused, or the influence is exerted to obtain an advantage at the expense of the confiding party, the person so availing himself of his position will not be permitted to retain the advantage, although the transaction could not have been impeached if no confidential relation had existed. (internal quotations omitted). To be clear, then, a plaintiff may recover damages from an abuse or breach of a confidential relationship only by showing that (1) the defendant was in a position to influence or control the plaintiff; (2) the defendant used the confidences given to him or her to obtain some benefit from, or advantage over, the plaintiff; and (3) the plaintiff, as the dominated party in the relationship, suffered some detriment at the hands of the defendant. See Mahunda v. Thomas, 55 Tenn. App. 470, 478, 402 S.W.2d 485, 489 (1965) (citing Peoples Bank v. Baxter, 41 Tenn. App. 710, 720-21, 298 S.W.2d 732, 737 (1956)); see also Kelly v. Allen, 558 S.W.2d 845, 848 (Tenn. 1977) (stating that “there must be a showing that there were present the elements of dominion and control by the stronger over the weaker”). In reviewing the complaint in this case, we find that the plaintiff has not stated a claim for inducement to breach a confidential relationship. While the physician-patient relationship can constitute such a relationship, see Shadrick v. Coker, 963 S.W.2d 726, 735-36 (Tenn. 1998); Turner, 191 Tenn. at 298, 232 S.W.2d at 271, the plaintiff has not alleged that her physician used the trust or confidences given to him either to obtain an advantage over her or to extract some benefit from her. Clearly, a physician’s revealing of confidences is not tantamount to a tortious breach of a confidential relationship—at least as that tort has been previously recognized in this state—unless that physician also uses the confidences given to him or her to obtain some benefit from, or advantage over, the patient.15 Because the complaint here does not allege that the Richardson Firm induced her physician to obtain any benefit or advantage for himself, we must therefore find that the 15 W e acknowledge that the plaintiff has alleged that the Richardson Firm obtained an advantage by inducing her physician to reveal information. However, because the plaintiff does not have a confidential relationship with the Richardson Firm, the complaint must allege that the Richardson Firm induced the plaintiff’s physician to obtain an advantage or be nefit for himself b y abusing the confidence placed in him by the p laintiff. See Mitchell, 779 S.W.2d at 389 . -23- complaint fails to state a claim for inducement to abuse or breach a confidential relationship. We affirm the judgment of the Court of Appeals on this issue. D. INVASION OF PRIVACY Finally, the plaintiff asserts that the Court of Appeals erred in dismissing her invasion of privacy claims. The complaint alleges that the Richardson Firm invaded her common law right of privacy by obtaining her medical information with defective subpoenas and that it invaded her right of privacy under the Patient’s Privacy Protection Act, Tenn. Code Ann. §§ 68-11-1501 to -1505 (2001), by having informal conversations with her physician without her consent. We address each of these claims separately. Common Law Invasion of Privacy With the exception of an action for false light invasion of privacy, see West v. Media Gen. Convergence, Inc., 53 S.W.3d 640 (Tenn. 2001), this Court has never expressly recognized that a cause of action exists for an invasion of privacy, though we have assumed that Tennessee law recognizes such an action in at least two cases, see Martin v. Senators, Inc., 220 Tenn. 465, 418 S.W.2d 660 (1967); Langford v. Vanderbilt Univ., 199 Tenn. 389, 287 S.W.2d 32 (1956). The Court of Appeals, on the other hand, has recognized that an unreasonable intrusion upon the seclusion of another is actionable in this state and that the scope of this tort is parallel to that contained in section 652B of the Restatement (Second) of Torts. See Roberts v. Essex Microtel Assocs., II, L.P., 46 S.W.3d 205, 211 (Tenn. Ct. App. 2001). Although we reach no decision as to whether the other forms of invasion of privacy listed in the Restatement (Second) of Torts are actionable—the plaintiff’s complaint does not raise issues related to commercial appropriation or unreasonable publicity—we agree with the Court of Appeals that a plaintiff may recover damages in Tennessee for an unreasonable intrusion into his or her private affairs. As the Roberts Court held, “‘One who intentionally intrudes, physically or otherwise, upon the solitude or seclusion of another or his private affairs or concerns, is subject to liability to the other for invasion of his privacy, if the intrusion would be highly offensive to a reasonable person.’” See id. at 211-12 (quoting Restatement (Second) of Torts § 652B). No especial publicity needs to be given to the plaintiff or to the plaintiff’s affairs, and a cause of action may be stated where the plaintiff shows an intentional, and objectively offensive, interference with his or her interest in solitude or seclusion. See Restatement (Second) of Torts § 652B cmt. a. Further, as comment c to section 652B provides, The defendant is subject to liability under the rule stated in this Section only when he has intruded into a private place, or has otherwise invaded a private seclusion that the plaintiff has thrown about his person or affairs. Thus there is no liability for the examination of a public record concerning the plaintiff, or of documents that the plaintiff is required to keep and make available for public inspection. -24- The essential question to be answered with respect to this issue, then, is whether the complaint has pled facts showing that the Richardson Firm “invaded a private seclusion that the plaintiff has thrown about [her] person or affairs.” Because a plaintiff cannot seek damages for intrusion into seclusion when he or she is required to make the allegedly private information available for public inspection, a plaintiff must allege and prove the following essential elements: (1) that the information sought by the opposing party was not properly discoverable or was otherwise subject to some form of privilege; (2) that the opposing party knew that the information was not discoverable or was subject to privilege, but nevertheless proceeded to obtain that information; (3) that the obtaining of such information would be highly offensive to a reasonable person; and (4) that injury was suffered from the invasion of privacy. The plaintiff here alleges none of these elements in her complaint, and she concedes that the substance of her medical information became discoverable, and subject to public disclosure, as soon as she filed a complaint seeking damages for physical injuries. However, no successful claim for invasion of privacy can rest only upon the technical defects in the process used to obtain that information, and a plaintiff must aver and prove that the defendant tried to obtain information that it knew was non-discoverable or subject to privilege. Therefore, because the plaintiff concedes that her medical information here was discoverable, we must hold that the plaintiff has failed to state a claim for common law invasion of privacy by intrusion into seclusion. Privacy Rights under the Patient’s Privacy Protection Act The plaintiff also alleges that the Richardson Firm violated her privacy rights under the Patient’s Privacy Protection Act by having informal conversations with her physician outside a deposition. The Patient’s Privacy Protection Act recognizes that all patients entering and receiving care at a licensed health care facility have “the expectation of and right to privacy for care received at such facility.” See Tenn. Code Ann. § 68-11-1503. To this end, section 68-11-1503 prohibits the divulging of a patient’s “name and address and other identifying information,” subject to four express exceptions. However, disclosing a patient’s identifying information in response to a subpoena does not violate the Act. See Tenn. Code Ann. § 68-11-1505.16 Upon review of the plaintiff’s allegations, we conclude that the plaintiff has not stated a claim against Allstate under the Patient’s Privacy Protection Act. The plain language of the Act provides a cause of action only for the divulging of protected information, not for the requesting or the obtaining of such information. By restricting the statute’s application only to those who divulge a patient’s identifying information, the General Assembly did not create a statutory action for the inducement to divulge identifying information. Therefore, because we will not construe statutory language to unduly expand it beyond its plain and obvious import, see Limbaugh v. Coffee Med. 16 To the extent that the plaintiff’s claims under this Act are for the divulging of non-identifying medical information, they may not fall within the scope of these statutes. See Tenn. Co de A nn. § 6 8-11 -150 3 (prohib iting only the divulging o f a patient’s “name and address and other identifying information”). Nevertheless, because her claims under the Act fail on other grounds, we need not comment further on this issue. W e also find it unnecessary to add ress whether a technically defective subpoena falls within the statutory exception contained in section 68-11-1505. -25- Ctr., 59 S.W.3d 73, 83 (Tenn. 2001), we hold that the statutory action established by section 68-111504 is available only against those persons who (1) have a statutory duty to keep identifying information confidential, and (2) actually divulge that information to parties not falling within a statutory exception. Accordingly, because the plaintiff here has not brought suit directly against her physician or other healthcare providers for divulging her identifying information, we must affirm the judgment of the Court of Appeals that the complaint does not state a claim for an invasion of privacy under the Patient’s Privacy Protection Act.