So what's up with the James Holmes case?

[wolfvgang22]

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I read a couple of articles yesterday like this Slate article and this article that indicate that Mr. Holmes had texted homicidal threats to his psychiatrist in Denver. That psychiatrist then informed university campus police about the threats and that Mr. Holmes might be a danger to others. I have two initial thoughts about this:

1. Why in the world would a patient be texting his psychiatrist on her cell phone? (Maybe that's not what really happened, but the articles say "texting" which usually is used to mean cell phone texting.) Isn't that perilously close to boundry crossing in the doctor-patient relationship? Seems ill-advised to be communicating by text with patients.

2. Why would a psychiatrist call a campus cop? Maybe I'm being sort of elitist, but I don't consider campus cops real cops much more than I consider natural health practioners real doctors. I would have called the actual Denver police myself. As a resident whenever I've called city police about a patient's threats, they do a well-person check and then usually take the patient to the nearest psychiatric ER for evaluation just to be safe since a physician was concerned about the patient.​

I know it's easy to second guess some other physician, when all we have are incomplete and possibly biased media reports.
Any comments or thoughts?

 

[TexasPhysician]

Yes, some psychiatrists allow texting/phone calls to cell and bill for it. I know a few psychologists that do this too.

Some schools use real and retired cops who understand the system quite well.

 

[notdeadyet]

2. Why would a psychiatrist call a campus cop? Maybe I'm being sort of elitist, but I don't consider campus cops real cops much more than I consider natural health practioners real doctors. I would have called the actual Denver police myself. As a resident whenever I've called city police about a patient's threats, they do a well-person check and then usually take the patient to the nearest psychiatric ER for evaluation just to be safe since a physician was concerned about the patient.[/INDENT]

Some college campuses have full fledged police departments that have patrol units, detecives, etc. and if a crime occurs on campus, you would contact the campus police. The rent-a-cop security guard at smaller colleges is not the norm at some of the larger colleges.

I also know of psychiatrists who leave their cell number on their office voicemail, saying "in case of emergency." I'd sooner roll naked over broken glass, but that's just me.

 

[AcronymAllergy]

Some college campuses have full fledged police departments that have patrol units, detecives, etc. and if a crime occurs on campus, you would contact the campus police. The rent-a-cop security guard at smaller colleges is not the norm at some of the larger colleges.

Yep. All of the colleges I've attended (there have been a few) have had relatively fully-functioning police departments...to the point that if you called the city police while on campus, they would forward your call to campus police and/or a campus police officer would always respond.

As for responses to calls about homicidal-type threats, that's going to vary by city. I've worked places where the sheriff's office would essentially say, "well ok, what do you want us to do about it?"

 

[wolfvgang22]

As for responses to calls about homicidal-type threats, that's going to vary by city. I've worked places where the sheriff's office would essentially say, "well ok, what do you want us to do about it?"

Yeah, I have had that happen once or twice before, too.
I've replied, "Well, this person is a danger to himself and others in my professional opinion, so if you don't do anything it's all on you, since I've reported it." So far that's gotten them to check up on a patient, and take them to the ER when the patient is obviously psychotic or threatening harm.

I wonder if any of the victims of the Aurora shooting are suing the campus police, since they may not have done much to protect the public once warned. It wouldn't surprise me.

 

[heyjack70]

She contacted the cops. I assume the campus police are actual police officers and not just security guards (if not, what she did was insufficient). I'm not sure what the Tarasoff law, or duty to warn law (or whatever it's called), is in Colorado. Some places you have to contact the target as well as police; in this case, I don't know if there was a clear target named to the psychiatrist. I think in some places you have to initiate an involuntary commitment if you think someone is at imminent risk of harming others. Tarasoff-like laws can be tricky depending on the state.

 

[NJWxMan]

As many have stated on here, many large universities have fully functional police departments (in fact, some have better police departments than the outlying city/township that the university lays withing). It's all about jurisdiction as well.

The question I have about the case is: how is the state going for the death penalty? We don't have many details at this point, but I question Holmes' grasp of reality leading up to the event. Some psychiatrists take a very paternalistic approach (me included) and I wonder whether he was psychotic and homicidal and no one stepped in and took charge.

 

[Therapist4Chnge]

Yes, some psychiatrists allow texting/phone calls to cell and bill for it. I know a few psychologists that do this too.

Outside of DBT programs....I have also seen this in private practice. A popular option is using Google Voice, which can forward phone calls (I'm not sure about txts...probably?) to a cell phone. It isn't something that I'd consider, but I guess some clinicians are okay with the setup.

 

[wolfvgang22]

As many have stated on here, many large universities have fully functional police departments (in fact, some have better police departments than the outlying city/township that the university lays withing). It's all about jurisdiction as well.

The question I have about the case is: how is the state going for the death penalty? We don't have many details at this point, but I question Holmes' grasp of reality leading up to the event. Some psychiatrists take a very paternalistic approach (me included) and I wonder whether he was psychotic and homicidal and no one stepped in and took charge.

Well, seeking the death penalty in this case has complex legal and ethical issues enough for a thread of it's own as part of societal debate. Personally, I never really bought the idea that a person should be treated differently for murdering others or commiting serious crimes because he or she may have been delusional. But maybe I'm wrong, there are some compelling arguments for the "not guilty by reason of insanity" defense.

 

[wolfvgang22]

Outside of DBT programs....I have also seen this in private practice. A popular option is using Google Voice, which can forward phone calls (I'm not sure about txts...probably?) to a cell phone. It isn't something that I'd consider, but I guess some clinicians are okay with the setup.

Good point about DBT. Now that you mention it, that's the only situation I'd accept phone calls on my cell phone from a patient. Even then, I would never allow texts. Too much room for misinterpretations. Heck, I am misunderstood here all the time, among fellow physicians and scholars! I can't imagine the disasters in doctor-patient texting if I were involved.

 

[nancysinatra]

She contacted the cops. I assume the campus police are actual police officers and not just security guards (if not, what she did was insufficient). I'm not sure what the Tarasoff law, or duty to warn law (or whatever it's called), is in Colorado. Some places you have to contact the target as well as police; in this case, I don't know if there was a clear target named to the psychiatrist. I think in some places you have to initiate an involuntary commitment if you think someone is at imminent risk of harming others. Tarasoff-like laws can be tricky depending on the state.

Not all states have adopted Tarasoff. Some have no laws at all about this. In some states, the doctor is not required to call anyone, but can use their discretion. Some prohibit calling the victim. You'd have to look up the exact language of the Colorado law to determine if contacting campus police is "insufficient." The officialness of the campus police hardly matters if the law only says "a relevant authority." And if there's any confusion, the matter would go to a jury I suppose.

And if by choice the doctor does call, they are not necessarily immune from HIPAA violation complaints. I know some state laws specifically say that a confidentiality violation can still be pursued.

Actually come to think of it, since Tarasoff laws differ by state, and there's no federal law that I know of on this, then would a HIPAA violation still have occurred? Couldn't Holmes file a HIPAA complaint with the federal government? And doesn't federal law trump state law? Of course he's got bigger problems to worry about. But in a case where the patient does NOT ultimately commit a crime, might they not want to file a complaint?

 

[heyjack70]

Not all states have adopted Tarasoff. Some have no laws at all about this. In some states, the doctor is not required to call anyone, but can use their discretion. Some prohibit calling the victim. You'd have to look up the exact language of the Colorado law to determine if contacting campus police is "insufficient." The officialness of the campus police hardly matters if the law only says "a relevant authority." And if there's any confusion, the matter would go to a jury I suppose.

And if by choice the doctor does call, they are not necessarily immune from HIPAA violation complaints. I know some state laws specifically say that a confidentiality violation can still be pursued.

Actually come to think of it, since Tarasoff laws differ by state, and there's no federal law that I know of on this, then would a HIPAA violation still have occurred? Couldn't Holmes file a HIPAA complaint with the federal government? And doesn't federal law trump state law? Of course he's got bigger problems to worry about. But in a case where the patient does NOT ultimately commit a crime, might they not want to file a complaint?

Absolutely correct.

 

[kugel]

HIPAA itself says that HIPAA does not prohibit releasing information where law (not just federal law) requires releasing otherwise confidential information, e.g. Infectious disease reporting and abuse reporting. State "duty to warn" laws are within this category, so there would be no HIPAA violation, and I have never heard of a HIPAA violation accusation when there is a credible threat and identifiable victims (even if the intended victim(s) are not named - as in "the tall thin guy at the liquor store at the corner of Maple and State.") Your documentation should show that you considered whether the situation meets the "duty to warn" and should include the specifics of why you believe the current situation meets the criteria of your local "duty to warn" laws. It also helps if you contact a colleague/supervisor, discuss the situation (without names), and document that conversation. It does not cause liability for them, but it does show any future reviewer that you took both options seriously and sought out a colleague's opinion. Your documentation should also include to whom you reported the threat, what info you conveyed, and what their reaction was.

I heard the threat against the owner of the liquor store noted above. I used the net to try to find that liquor store, but there are several, and it did not seem right to release this pt's info to all the people who work at all those stores. But when I called the police, the watch commander for that sector knew which store owner was being referenced and said, "I know who it is. I'll contact him and let him know," and I included that quote in my notes.

 

[PikminOC]

DEPARTMENT OF HEALTH & HUMAN SERVICES Office of the Secretary
Director
Office for Civil Rights
Washington, D.C. 20201
January 15, 2013

Message to Our Nation's Health Care Providers:

In light of recent tragic and horrific events in our nation, including the mass shootings in Newtown, CT, and Aurora, CO, I wanted to take this opportunity to ensure that you are aware that the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule does not prevent your ability to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when you believe the patient presents a serious danger to himself or other people.

The HIPAA Privacy Rule protects the privacy of patients' health information but is balanced to ensure that appropriate uses and disclosures of the information still may be made when necessary to treat a patient, to protect the nation's public health, and for other critical purposes, such as when a provider seeks to warn or report that persons may be at risk of harm because of a patient. When a health care provider believes in good faith that such a warning is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, the Privacy Rule allows the provider, consistent with applicable law and standards of ethical conduct, to alert those persons whom the provider believes are reasonably able to prevent or lessen the threat. Further, the provider is presumed to have had a good faith belief when his or her belief is based upon the provider's actual knowledge (i.e., based on the provider's own interaction with the patient) or in reliance on a credible representation by a person with apparent knowledge or authority (i.e., based on a credible report from a family member of the patient or other person). These provisions may be found in the Privacy Rule at 45 CFR § 164.512(j).

Under these provisions, a health care provider may disclose patient information, including information from mental health records, if necessary, to law enforcement, family members of the patient, or any other persons who may reasonably be able to prevent or lessen the risk of harm. For example, if a mental health professional has a patient who has made a credible threat to inflict serious and imminent bodily harm on one or more persons, HIPAA permits the mental health professional to alert the police, a parent or other family member, school administrators or campus police, and others who may be able to intervene to avert harm from the threat.

In addition to professional ethical standards, most states have laws and/or court decisions which address, and in many instances require, disclosure of patient information to prevent or lessen the risk of harm. Providers should consult the laws applicable to their profession in the states where they practice, as well as 42 CFR Part 2 under federal law (governing the disclosure of substance abuse treatment records) to understand their duties and authority in situations where they have information indicating a threat to public safety.

Page 2 – Nation's Health Care Providers

We at the Office for Civil Rights understand that health care providers may at times have information about a patient that indicates a serious and imminent threat to health or safety. At those times, providers play an important role in protecting the safety of their patients and the broader community. I hope this letter is helpful in making clear that the HIPAA Privacy Rule does not prevent providers from sharing this information to fulfill their legal and ethical duties to warn or as otherwise necessary to prevent or lessen the risk of harm, consistent with applicable law and ethical standards.

Signed-Leon Rodriguez