Question: Is calling police on a HTN Crisis patient a HIPAA violation?

[whopper]

You got a patient in your office, she was veering in and off the road due to dizziness and confusion. She gets to your office, you take her BP and she's in HTN crisis (yes you triple-checked, she has a history of an MI, prior badly controlled HTN).

You tell her she's in HTN crisis, you offer to have an ambulance bring her in to the hospital and she refuses. You explain to her the risks, and tells you she understands, but doesn't want to go to the hospital. She shows no signs of gross cognitive deficits but is telling you she's dizzy and not able to drive well. She later compromises and tells you she will drive to the closest hospital on her own but she doesn't want the police or an ambulance involved. You tell her she's a risk if she drives herself because she could stroke at any moment?

Do you let her leave the office? Do you call 9-1-1 telling them your patient's personal information?

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[WisNeuro]

Not sure about HIPAA per se, but there are a lot of reporting issues that depend on the state laws. In my state, I can report PHI if I feel that the pt is an "imminent danger" to themselves or others by operating a motor vehicle when they leave my office without it being a violation. So, I have to honestly believe that they are going to most likely get into a car accident when they leave my office. However, if I believe that they are at increased risk, but not quite imminent, then I can not make that call without a possible violation.

 

[whopper]

While I was in residency a similar situation happened. The pt already had a stroke but his BP wasn't stabilized. I called the hospital lawyer and he told me so long as the patient has capacity you can't hold the patient. So he was let go, he had a stroke while driving home and crashed his car. His car was totaled but thankfully he didn't hurt himself or anyone else (other than that the stroke is serious harm).

Despite the above I still really think the lawyer was in the wrong cause of the imminent danger aspect.

 

[michaelrack]

A HIPAA covered entity also may disclose PHI to law enforcement without the individual's signed HIPAA authorization in certain incidents, including: To report PHI to a law enforcement official reasonably able to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public.

https://www.hhs.gov/sites/default/f...ergency/final_hipaa_guide_law_enforcement.pdf

 

[whopper]

Well there you go! And cause HIPAA is federal it applies to all 50 states.

Seems then that lawyer was wrong!

 

[FlowRate]

Well there you go! And cause HIPAA is federal it applies to all 50 states.

Seems then that lawyer was wrong!

Seems like there was a difference in the facts you gave us between the two cases--were you certain the stroke patient was so impaired that he was going to crash his car after leaving the hospital? You seemed to imply that he was without deficit and simply a bit hypertensive--you had no way of knowing for sure that the stroke would worsen--whereas your HTN patient is currently impaired.

 

[whopper]

He was without cognitive deficit. He had capacity by it's legal definition. Further his BP wasn't yet stabilized thus putting him in high risk for another stroke during his trip home, that would've been over a 2 hr ride. Remember capacity is moment to moment. He could lose it say 20 seconds from then but if he has it at that moment he has it and is supposed to be entitled to the rights that come from it.

But again he wasn't cognitively impaired. He had capacity to understand the risks of driving home, was able to state them, and acknowledged he was at high risk for another stroke. He did fine on several mental tasks that were given to him.

-were you certain the stroke patient was so impaired that he was going to crash his car after leaving the hospital?

No-the exact % risk here is not discernable. We know that if someone's BP isn't stabilized after a stroke they're at increased risk of another one. No one to my knowledge has ever put a risk stratification of the exact BP and the exact risk of stroke, but he was in a situation where "within reasonable medical knowledge" he was at increased risk, and I didn't think he was safe for that reason despite that he had capacity.

Even if we had a knowable 50-50% chance of restroking during the car drive that's not certainty he's going to stroke but that's damned dangerous to let him on the road.

I do remember bringing up (or at least I thought I did, this was over 10 years ago) that I believed he was an imminent risk and the lawyer specifically said I could only alert the authorities if he lacked capacity due to a mental illness and his denialism wasn't considered that. I also told the lawyer something to the effect of, "I can imagine the hospital being in the news when this guy strokes and crashes his car into some little kid," but his answer was the same.

 

[wolfvgang22]

A similar sort of thing happens in my Neurocognitive Disorder clinic all the time. Sometimes, a patient with dementia refuses to stop driving when his or her cognition worsens to the point they get lost or get easily confused by traffic. Often vision and hearing are impaired.

My state's laws say it is optional for doctors to report such patients to the DMV for evaluation of their ability to safely drive. I used to report such patients. However, my employer distributed a policy last year saying that physicians in our organization can no longer report these patients because it is a HIPPA violation. But we can call police if the threat of harm to self or others is imminent. I'm not at all comfortable knowing patients like this are driving around.

Most of the time in my clinic we are able to get the patient's family to take away the keys, but sometimes sadly there is no family or friends willing to step up. I will then have to call police if neccessary for safety as a practical matter.

 

[Crayola227]

Well there you go! And cause HIPAA is federal it applies to all 50 states.

Seems then that lawyer was wrong!

Lawyers have different goals typically, which is to be conservative and play it safe with regard to legal risk. Rather than taking an action that is likely legal, but does open you up to possible legal action, they will tell you not to do stuff, even if it seems it would go in your favor.

Of course, that doesn't factor in the legal liability if you let someone go, don't report, and something bad happens....

I'm not a lawyer but my feeling is that in this sort of case you have more of a defense in one circumstance than the other. Not to mention, I don't make clinical decisions based purely on law and avoiding liability. There's one's sense of ethical duty, integrity, and oath to consider. That's likely naive and must be compromised in a lot of situations. Still. One thing I do think about.

 

[hamstergang]

He was without cognitive deficit. He had capacity by it's legal definition.

Capacity has nothing to do with it. You're calling the police due to an imminent public health/safety threat.

 

[witzelsucht]

" telling you she's dizzy and not able to drive well"

So, it sounds like the diagnosis is hypertensive encephalopathy with a neurological deficit (dizziness) - 911 for that. The risk isn't that she "could stroke," its that she is already having cerebellar dysfunction and should not be driving.

 

[whopper]

Capacity has nothing to do with it. You're calling the police due to an imminent public health/safety threat.

Agree. In psych ER we called the cops all the time on patients that weren't mentally ill that we were discharging that we thought were an imminent danger. And as most of you know I'm a forensic psychiatrist! One of those old memories of mine where I thought the other guy was wrong, let the memory linger, but didn't resolve it with my other training in my own head. The neural connection wasn't made until bringing it up here (and Michael Rack!)

 

[Crayola227]

Yeah looking at this thread again (thank you Tapatalk) seems like there is a difference between criteria for a psych hold, and when a patient has capacity but is an imminent danger for a different reason.

The lawyer may not have been wrong that you couldn't hold the patient, but did they say no you can't hold but yes you can call the cops? Or did that not get addressed? Sometimes a lawyer's answers are only as good as the question posed to them.

Seems to me in the example of the post stroke patient with capacity that you think is an imminent danger to drive, you can't hold but it isn't a HIPAA violation to call the cops.

 

[Radetzky]

Just by the by a patient presenting with altered mental status and hypertension is much more likely to have had a cerebral event and hypertension in response to that, rather than “hypertensive crisis” which is increasingly believed to not really be a diagnosis. Hypertensive PRES does occur but is much less common than this scenario.

With regards to your stroke patient, hypertension confers an increased risk of re-stroke in the medium to long term, not during the 2 hour car ride home.