Opinion ID: 2283325
Heading Depth: 1
Heading Rank: 6

Heading: Application of HIPAA's Enumerated Exceptions Prohibition of ex parte Communications

Text: HIPAA's regulation that prohibits the unauthorized disclosure of a patient's protected health information, however, does include enumerated exceptions to the ban: (1) Permitted uses and disclosures. A covered entity is permitted to use or disclose protected health information as follows: (i) To the individual; (ii) For treatment, payment, or health care operations, as permitted by and in compliance with § 164.506; (iii) Incident to a use or disclosure otherwise permitted or required by this subpart, provided that the covered entity has complied with the applicable requirements of § 164.502(b), § 164.514(d), and § 164.530(c) with respect to such otherwise permitted or required use or disclosure; (iv) Pursuant to and in compliance with a valid authorization under § 164.508; (v) Pursuant to an agreement under, or as otherwise permitted by, § 164.510; and (vi) As permitted by and in compliance with this section, § 164.512, or § 164.514(e), (f), or (g). 45 C.F.R. § 164.502(a) (emphasis added). For example, under 45 C.F.R. § 164.502(a), HIPAA permits ex parte communications between a physician and a third party when the patient expressly authorizes the ex parte communications by issuing a valid authorization pursuant to 45 C.F.R. § 164.508(a)(1), which says: Except as otherwise permitted or required by this subchapter, a covered entity may not use or disclose protected health information without an authorization that is valid under this section. When a covered entity obtains or receives a valid authorization for its use or disclosure of protected health information, such use or disclosure must be consistent with such authorization. In this case, however, the plaintiff did not issue an authorization under 45 C.F.R. § 164.508(a)(1). Instead, the trial court issued a purported order directed to non-party medical providers who had provided treatment to the plaintiff authorizing such medical providers to engage in ex parte communications with the defendant's attorneys [6] because it believed that its purported order fell under 45 C.F.R. § 164.502(a)'s exceptions for disclosures that are permitted under 45 C.F.R. § 164.512(e). The trial court's purported order states, in pertinent part: TO: All Hospitals, Clinics, Pharmacies, Physicians, Social Workers, Educators, Psychiatrists, Psychologists, Therapists, Governmental Agencies, (State and Federal); All Other Medical Institutions, Practitioners, Health Care Providers, Past and Present. . . . . You are further notified that, pursuant to federal and state law, counsel for the defendants are hereby authorized to talk with Bobbie Jean Proctor's treating physicians or other health care providers, without counsel or the parties, including the plaintiff, being present or participating, provided the health care provider consents to the interview. This is based on the Court's finding that the plaintiff has made a claim for personal injuries, and in filing this lawsuit has waived any privilege existing between the patient and health care provider. This Order does not require you to meet or speak with any attorney in this proceeding. You have the right to decline an attorney's request to speak or meet with you informally. . . . . This Order complies with HIPAA federal standards for privacy of individual health information, 45 C.F.R. Parts 160 and 164.... This Court further enters a qualified protective order consistent with 45 C.F.R. 164.512(e)(1). Specifically, the parties are prohibited from using or disclosing the protected health information of Bobbie Jean Proctor for any purpose other than this litigation. Further, the parties agree to return to the covered entity or destroy the protected health information (including all copies made) at the end of this litigation. (Emphasis removed.) Under 45 C.F.R. § 164.512(e)(1), HIPAA authorizes disclosure in the course of any judicial or administrative proceeding: (1) Permitted disclosures. A covered entity may disclose protected health information in the course of any judicial or administrative proceeding: (i) In response to an order of a court or administrative tribunal, provided that the covered entity discloses only the protected health information expressly authorized by such order; or (ii) In response to a subpoena, discovery request, or other lawful process, that is not accompanied by an order of a court or administrative tribunal, if: (A) The covered entity receives satisfactory assurance, as described in paragraph (e)(1)(iii) of this section, from the party seeking the information that reasonable efforts have been made by such party to ensure that the individual who is the subject of the protected health information that has been requested has been given notice of the request; or (B) The covered entity receives satisfactory assurance, as described in paragraph (e)(1)(iv) of this section, from the party seeking the information that reasonable efforts have been made by such party to secure a qualified protective order that meets the requirements of paragraph (e)(1)(v) of this section. (Emphasis added.) The trial court is correct that the Secretary created exceptions to HIPAA's general prohibition on the disclosure of plaintiff's protected health information and that some of those exceptions are listed in 45 C.F.R. § 164.512(e). The trial court, however, erred in its application of 45 C.F.R. § 164.512(e)(1) to this case because the plain and ordinary language of 45 C.F.R. § 164.512(e)(1) does not authorize the disclosure of protected health information during a meeting in which an attorney, without express authorization of the patient, has ex parte communications with a physician. Stated another way, 45 C.F.R. § 164.512(e)(1) permits a health care provider to disclose otherwise protected health information in the course of any judicial or administrative proceeding if that disclosure is in response to (i) an order of a court, or (ii) in response to a subpoena, discovery request, or other lawful process, that is not accompanied by an order of a court. (Emphasis added). Thus, by the express language of 45 C.F.R. § 164.512(e)(1), the covered entity's disclosure must occur in the course of a judicial proceeding, and it must be made in response either to a formal process, whether in the form of a court order, discovery request or other lawful process. The meaning of a term can vary depending on the context of its use. For instance, when a statute in question fails to provide a statutory definition, and there is no case law interpreting the term in the context of the statute, then the Court presumes that the term is used according to its plain and ordinary meaning. The term judicial proceeding would be commonly understood to refer to a case filed in a judicial forum. In the course of a judicial proceeding, thus, would be commonly understood to include matters that occur while a case is pending in a judicial forum. This is consistent with the dictionary definition of in the course of, which defines in the course of as (1) undergoing the specified process ... (2) during the specified period ... (3) during and as part of the specified activity. THE NEW OXFORD AMERICAN DICTIONARY 389 (2nd ed.2005). The dictionary may be used to derive the plain and ordinary meaning of a term. Tendai v. Mo. Bd. of Registration for the Healing Arts, 161 S.W.3d 358, 366 (Mo. banc 2005) ( overruled on other grounds ). In the context of defamation, however, the phrase judicial proceedings has been interpreted more broadly because of the nature of the privilege involved. Roberson v. Beeman, 790 S.W.2d 948, 950 (Mo.App. 1990), held that a demand letter sent before trial was considered within judicial privilege because published in the course of a judicial proceeding. See also Pape v. Reither, 918 S.W.2d 376, 381 (Mo.App. 1996) (settlement letter sent before trial is within judicial proceedings for purposes of the judicial privilege against defamation). By contrast, the Missouri legislature, for purposes of a criminal statute, defined judicial proceeding narrowly as any official proceeding in court, or any proceeding authorized by or held under the supervision of a court [.] § 575.010(4), RSMo Supp. 2009 (emphasis added). BLACK'S LAW DICTIONARY 122 (5th ed.1979) (citation omitted) defines authorize as: [t]o empower, to give a right or authority to act. To endow with authority or effective legal power, warrant, or right. To permit a thing to be done in the future. It has mandatory effect or meaning, implying a direction to act. Authorized is sometimes construed as equivalent to permitted; or directed, or to similar mandatory language. Possessed of authority; that is, possessed of legal or rightful power, the synonym of which is competency. BLACK'S LAW DICTIONARY defines supervision as [a]n act of occupation of supervising; inspection. Id. at 1290. It also defines supervise as [t]o have general oversight over, to superintend or to inspect. Id. While neither HIPAA nor its regulations expressly define in the course of or judicial proceeding, or expressly state whether the term should be given its common, narrow or broad legal definitions, a narrow definition is implicit in HIPAA's regulatory requirement in 45 C.F.R. § 164.512(e)(1) that a covered entity may make disclosures only pursuant to a court order or subpoena, discovery request, or other lawful process. The Secretary has stated that this means that: In § 164.512(e) of the final rule, we permit covered entities to disclose protected health information in a judicial or administrative proceeding if the request for such protected health information is made through or pursuant to an order from a court or administrative tribunal or in response to a subpoena or discovery request from, or other lawful process by a party to the proceeding. Standards for Privacy of Individually Identifiable Health Information, 65 Fed. Reg. 82462, 82529 (Dec. 28, 2000) (emphasis added). In other words, such disclosure must be under the supervisory authority of the court either through discovery or through other formal court procedures. This regulation does not itself authorize any additional process or procedure for obtaining a court order, subpoena, or other lawful process; that is left to the rules in the individual states. [7] In this context, under Missouri's civil procedure rules, the trial court has the authority and oversight over: (1) pretrial motion proceedings and trial ( i.e., official proceedings in court) and (2) formal discovery ( i.e., proceedings authorized by or held under the supervision of a court). State ex rel. Norman v. Dalton, 872 S.W.2d 888, 891 (Mo.App.1994). None of these rules authorizes an order directing or authorizing a physician to engage in ex parte communications. Missouri case law is clear that while Missouri law has not prohibited a party from engaging in voluntary ex parte communications with a treating physician, the trial courts have never supervised these communications nor exercised authority over them, and the trial courts have not had authority to compel a plaintiff to expressly authorize ex parte discussions with her physician. Brandt I, 856 S.W.2d at 661; Woytus, 776 S.W.2d at 392. Further, the trial courts had no authority to force a physician, over his own objection, to engage in informal ex parte discussions with an attorney during discovery. Brandt I, 856 S.W.2d at 662. Given Missouri's law on the subject of ex parte physician communications, the meeting at which ex parte communications occur is not a judicial proceeding because the trial court has no general oversight of the meeting or any control over it. [8] Thus, 45 C.F.R. § 164.512(e), which permits disclosures in the course of judicial proceedings, does not apply to a meeting for ex parte communications, and consequently, a trial court has no authority to issue a purported HIPAA order advising the plaintiff's nonparty treating physicians that they may or may not participate in informal discovery via ex parte communications. In both Brandt opinions, this Court reiterated its conclusion that a plaintiff cannot be compelled by a trial court to sign an authorization consenting to ex parte communications with his treating physicians in favor of defendants or their attorneys. The rationale for the holdings of the Brandt opinions is particularly relevant to this Court's resolution of this case today: [T]his court will not require that a nonenumerated discovery method be added to those already available under the [Missouri Rules of Court]. Information or evidence that can be obtained legitimately through ex parte discussion [with treating physicians] can also be obtained through the methods of discovery listed in the [Missouri Rules of Court]. Any burdens caused defendants by being restricted to the specially enumerated discovery procedures are outweighed by the potential risks to the physician-patient relationship in deviating from those procedures. Woytus, 776 S.W.2d at 395. The rules of discovery enumerated by this Court are found at Rules 56 to 61. These rules provide the trial court discretion to issue orders relating to the perimeters of interrogatories, depositions, production of documents, requests for admission, physical and mental examinations, and discovery sanctions. The defense in this case concedes that there is no discoverable information that they could obtain from an informal ex parte discussion with the treating physician that they could not obtain by use of these rules of discovery. However, there is nothing in these rules of discovery that authorizes the trial court to issue orders governing methods of informal ex parte communications with plaintiff's nonparty treating physicians. Likewise, there is no regulation in the HIPAA framework that authorizes a trial court in Missouri to issue an order permitting a physician to divulge a patient's protected health information outside the confines of a judicial proceeding over which the trial court has direct supervision thereof. Compliance with HIPAA and this Court's rules of discovery will ensure the disclosure of the health information and at the same time limit the potential liability of a treating physician who was prompted to provide protected health information. [9] The treating physician in this case can comply with HIPAA by not giving an ex parte interview without an authorization and also comply with Missouri common law by choosing not to grant the ex parte interview. [10]