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Health Board Grapples With Aliases

June 19, 2008

By Robert Boyer, Times-News, Burlington, N.C.

Jun. 19–The Alamance County Board of Health has, for now, resolved the question of how to handle the records of Health Department clients who go by more than one name, but only after a lengthy debate and some compromise. The debate was over, in large part, whether such aliases are part of a client’s medical records.

The compromise centered on whether such information should be reported to authorities to determine whether illegal immigrants are using false names to break laws, and whether health department workers are committing a crime when they write “work notes” for such clients.

Typically, a couple or so times a month, Hispanic patients ask medical staffers to use an alternate name when writing sick notes to their employers, department officials say.

Board Chairman Keith Whited, a Burlington attorney running for a district court judgeship, thinks writing notes with false names violates state and federal law and helps illegal immigrants to do the same.

At the board’s meeting on Tuesday, the board, at Whited’s urging, voted 7-0 to require the health department to “maintain accurate, complete and organized medical records on each patient” and authorize the health board as an oversight agency to ensure compliance. The amendment still requires the board to maintain the confidentiality of the records.

Whited’s second draft amendment, which in part covered the use of false names in work notes, sparked strong opposition and the compromise.

In Whited’s initial draft of the latter amendment to existing department policy, all identifying information of a patient must be kept only in a patient’s medical record. Patients also must sign an agreement “permitting all of the different name and identifying information … to be released at the same time” to non-medical third parties. The signatures would also authorize the sheriff’s department to “make an independent determination that the names used by the patients are not a part of any wrongful conduct, including identity theft.” The patient must also “certify that the name and personal identifying information” in the medical record “is my true and lawful name,” Whited said.

“Anybody who is using an alias name for a lawful purpose will not mind signing that,” he said.

Several board members balked at Whited’s second amendment. Dr. Don Courtney, a veterinarian, said forcing clients and staffers to release such information to the sheriff’s department might hurt the department’s primary mission of “keeping everyone as healthy as we can.” Dr. Michael Blocker questioned whether the health department should get involved in helping authorities determine the legal status of its patients.

“Why are we trying to verify who people are?” Blocker asked. “Do we not provide services to illegal immigrants?” The department’s mandate, Blocker said, is to provide health care to all county residents, not to verify identity. Writing work notes with aliases doesn’t verify or vouch for a person’s identity, he said.

Legal residents sometimes use “fake names” when seeking treatment for sexually transmitted diseases and get work or school notes in those names, Blocker said. He questioned whether that was illegal.

Board member and county Commissioner Bill Lashley said anyone giving a false name at the health department is guilty of a felony and a department employee is breaking the law when they provide a false name for a client to an employer.

“A company cannot hire a person … in the United States if they are illegal,” Lashley said.

“Did they get the job because we wrote a letter?” Blocker asked.

“They keep their job because we wrote a letter,” Whited said.

“How are we going to know if someone comes in with a fake ID” and other forms of information, Blocker said.

Blocker wants the county attorney to specifically address whether writing work notes with aliases is illegal. “I don’t think it’s an issue for someone with an alias to come in and get care,” he said.

The sheriff’s verification would keep the department out of potential legal trouble, Whitehead said.

Forcing every patient to sign such an agreement would cause some patient with communicable diseases not to seek care, Blocker said. “They’re more likely to go to work … and potentially put the public health at risk.” Dr. Kathleen Shapley-Quinn, the department’s medical director, said the verification requirement could lead to a flood of additional paperwork.

Courtney also questioned the wisdom of requiring the verification of every client’s identity.

The policy “needs to apply to every patient that we see,” Whited said. “If this is the effort that we have to go through to ensure that we’re not complicit in the commission of crimes in this department, then that’s the effort I want us to go through, even if we have to hire a separate person to do it.” Whited ultimately withdrew his second motion and inserted in its place a draft calling for patients to sign a form authorizing and requiring the release of all names and identifying records to “non-medical third parties” but leaving out the requirement to send the information to the sheriff’s department.

That would mean that doctor’s notes would include all names for the patient provided to the department.

The draft passed by a 6-1 vote, with Blocker the lone dissenter.

THE ISSUE FIRST surfaced during the May 20 meeting of the Personal Health Committee, a board subcommittee.

According to a memo from Whited, that’s when Marilyn Burns, the department’s nursing director, gave a report about clients with multiple names and the use of aliases in work notes.

Her report, Whited said Tuesday, came after a Health Department client was charged with committing identity theft. The charges are still pending in an Alamance County court, Whited said.

To “keep these differing names identified,” a health department staffer keeps a list or “some writing” of aliases “outside the medical record of the patient,” Whited wrote in his memo. The “limited staff that has possession of this information, continues to evade my request to review the documents and present them” to the board “for oversight/audit purposes.” Whether to use aliases when writing work notes for patients first came up in summer 2007, when the health department’s medical staff asked for instruction on how to deal with the situation, Dr. Shapley-Quinn said during Tuesday’s meeting.

The medical staff writes only two or three such notes a month that use aliases, but nevertheless wanted guidelines for what Shapley-Quinn called a “complex” issue.

Shapley-Quinn said she instructed the medical staff a month or so ago to use only a patient’s “primary name” on the medical record until the issue was resolved.

Caring for patients is complex and involves balancing “competing priorities and values,” such as in the case of when a client threatens to harm himself or someone else, Shapley-Quinn said.

“I don’t think anybody in our health department thinks of this as an easy or obvious answer.” Whited disagreed with Shapley-Quinn’s assessment and said he was a “little bit disappointed” in the staff’s handling of the issue. “To me, it’s not a complex issue,” he said.

“If it’s a medical record and it’s kept outside of the medical record, then that’s a violation of HIPAA,” Whited said. (HIPAA is a set of federal laws and guidelines that cover the privacy of patient records, among other things.) Under a HIPAA exception, the health board has the authority to review such records, Whited said.

The staff isn’t following department policy and its refusal to “deliver documents” is “bordering on insubordination,” Whited said.

Shapley-Quinn said there isn’t a list, but rather a “tracking system for how to follow up on information.” The doctor said she informed interim Health Department Director Tim Green that he can access the records and turn it over to the board.

“I don’t feel like I’m any barrier to producing that information,” Shapley-Quinn said. “I think it’s the law that keeps me from releasing that information unless there’s clarity” from Assistant County Attorney Clyde Albright about who can legally review medical records.

“He clarified it for me in one sentence. It’s the same thing that I told you a month ago,” Whited said.

In an e-mail to Whited on Tuesday morning, Albright said this: “In my opinion the Board of Health is a health oversight agency as that term is defined by HIPAA. As a health oversight agency the Board of Health may receive disclosures of medical information for purposes of oversight, compliance with laws and correction.” To comment on this or any Times-News story online go to www.TheTimesNews.com, find the story, go to the bottom and follow the directions

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