Patient access to records: the invisible confidentiality right
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Patient access to records:
the invisible confidentiality right
Author: Bruce Borkosky, Psy.D.1
Journal: The National Psychologist, 22(5), 9-10.
Cite: Borkosky, B. G. (2013). Patient access to records: The invisible confidentiality right. The National Psychologist, 22(5), 9-
10.
CONFIDENTIALITY WAS ALWAYS REQUIRED, BUT ACCESS IS NEW
Confidentiality1 has been around since Hippocrates. In contrast, the patient’s right to obtain a
copy of her records (patient access2) is a relatively recent concept. This may be a surprise, be-
cause patients have had a legal right to their records for 30+ years. However, prior to the 1970’s,
patients had no right to access their records. No state or federal statutes required it, and profes-
sional associations3 advocated denial. Some patients had to obtain a court order to gain access4.
The APA has been a laggard here. The first mention of access rights occurred in 19925, but only
in regards to test data, and only as an exception to confidentiality (2.02). Psychologists could
withhold records, except to patients; but psychologists were permitted to withhold access if they
determined the access was “inappropriate”. It wasn’t until the enactment of HIPAA6, that the eth-
ics code began to address access rights.
ACCESS IS NOT REQUIRED BY THE APA
Although HIPAA mandates access, official APA policy sees things differently. Here is a sam-
pling:
- The Forensic Guidelines7 - a forensic patient has no right of access.
- The Record Keeping Guidelines8, ASPPB Code of Conduct9, ASPPB Model Act10, Rights
and Responsibilities of Test Takers11, and Guidelines for Test User Qualifications12 each
refer to confidentiality, but do not mention access rights.
- Although the 2002 ethics code13 requires release of test data with a written release (9.04a),
records can be withheld by institutional policy or legal proceedings (3.05c), courts (9.04b),
and organizational clients (4.05a). Finally, psychologists are not required to release records
(using the permissive “may” 4.05a).
1
Independent Practice. forensicpsychologist@outlook.commailto:drborkosky@gmail.com, 800-919-9008, skype: Bruce-
Borkosky
Page 1PRACTITIONERS OFTEN REFUSE ACCESS
This position by the APA may be part of the reason that access to records has been14, and
continues to be15, controversial16, and a topic of heated listserve discussions17. Psychologists re-
fuse to release records to patients18, third parties19, the courts20, non-psychologists21, and attor-
neys22, sometimes enlisting the Court in their efforts23 (although courts are rarely supportive24).
Denial of access is a top Health Insurance Portability and Accountability Act (HIPAA) complaint
against healthcare providers.25,26 Many states have laws that prohibit release of test data to
nonpsychologists.27
HOWEVER, ACCESS IS REQUIRED BY LAW
This denial or access is surprising, because state and federal laws require access. Every
state except for three (NC, IA, WY) has laws requiring access28,29,30,31. Further, for the vast ma-
jority of psychologists who are regulated by HIPAA, HIPAA preempts any state laws that might
limit access32.
Finally, patient access is ethical:
AUTONOMY
The EPPCC uses an unusual wording for Principle E (normally referred to as autonomy33),
perhaps to emphasize that respect for autonomy requires more than acquiescence to the patient’s
choices – it’s a positive obligation. One should actively enable the patient’s capacity for free
choice, including disclosing information to the patient that increases understanding, fosters deci-
sion making, and nurtures their capacity as a free agent.
Privacy, confidentiality, privilege, informed consent and access comprise these infor-
mation-based facets of the autonomy right. Patients decide to consent to services. Then they
choose to share private information with the psychologist, and finally, determine whether (and
with whom) to disclose that information to third parties. Psychologists demonstrate respect for
these rights by obtaining written informed consent to treatment and written authorization to re-
lease information. Exactly as we demonstrate respect for the patient in handling their information
in these ways, we should also respect the patient enough to let them know what information is
contained in those records. Further, access is consistent with informed consent – a patient must
know what information is going to be released, so they can determine whether to release the rec-
ords.
NONMALEFICENCE
A number of scholarly arguments have offered as reasons to withhold access34. Some scholars be-
lieve that the patient might be harmed by the information in the records.35,36,37 However, there is
little empirical evidence of such harm38, and there is evidence of no harm.39,40 On the other hand,
patients may be harmed when access is refused. Records may contain errors, other professionals
may need the records to perform their jobs, and the patient may need access in order to make im-
portant decisions. If the information is needed by the patient or others, refusing to release the rec-
ords can result in harm to the patient.
HONESTY (INTEGRITY)
Honesty refers to comprehensive, accurate, and objective transmission of information, in-
cluding patient understanding. When we withhold information, we convert our relationship with
the patient from one of respect to paternalism; we make the patient dependent vulnerable to a
Page 2range of future harms.41 Others may wonder what we have to hide. Conversely, access to records
increases openness and transparency, and is itself clarifying.
JUSTICE
Justice is a broad topic, far too wide-ranging for our discussion here. However, in part, jus-
tice refers to fairness, protection of civil liberties,42 equal treatment,43 equitable distribution of
services, and guarding against bias and prejudice44. Under various theories of justice, it can be ar-
gued that patient control over, and access to, their records is just. According to formal justice,
equals should be treated equally; when some patients are permitted access to their records but oth-
ers are not (e.g., clinical vs. forensic), equals are treated disparately and unjustly.45 Under Liber-
tarian views of justice, control over the distribution of one’s records affirms an individual’s lib-
erty and property rights.46 Courts have established the patient’s common law property right to the
information in their records47. The transfer of this informational ‘property’, is only just if it is
freely chosen by the patient.
In summary, although required by law, psychologists often refuse to release records. Alt-
hough permitting access is the more ethical path, it’s surprisingly absent from APA ethical guide-
lines. Psychologists who believe that refusing to release records is ethical may face (in additional
to legal sanctions), a serious ethical dilemma, when organizations such as the Veteran Admin-
istration make access easier by placing records online. The APA should clarify this issue in future
guidelines.
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