Need opinions from RN's for my Ethical Dilemma Assignment!

  1. 0 So far, everyone has split opinions...

    "Jane works in the ED part time as a tech and goes to nursing school. She was working one day when a "once in a lifetime" patient came in with an issue that brought about a head scan that none of the doctors in the ED had seen to date in their 200+ years total of experience.
    Jane wanted to take a picture of the scan for educational purposes. She asked the very well respected doctor who was caring for the patient, who had also been the nursing director. The Physician agreed happily and told her to make sure the picture she took with her phone did not have any identifying features in it, and Jane did as instructed. There were no numbers or letters on the scan that would identify the patient.
    Jane was excited to share her great scan with her instructor who she trusted in the educational setting. She had not shown anyone, and in private, she showed her instructor while telling the instructor about what she had learned. In a very concerned tone of voice, the instructor said to delete it immediately and she had violated Hipaa."

    Did Jane violate Hipaa law? Or is this a grey area untouched by the law? Should Jane be taken out of nursing school?
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  3. Visit  StudentOnTheEdge profile page

    About StudentOnTheEdge

    Joined Apr '12; Posts: 3.

    22 Comments so far...

  4. Visit  RNsRWe profile page
    6
    i do believe hipaa was violated. reasoning is, in this case it was so unique a medical circumstance, that the identifier was the image. no names or account numbers were necessary, because the very uniqueness of the image will identify this patient. i don't think the area of the law is grey on this one.

    actually, this reminds me of a very recent case in which an aide took a photo of a patient's buttocks and posted them on facebook. i realize the student in the hypothetical situation didn't post them, but my point is the photo showed unique wounds that did identify the patient to the person(s) who viewed the fb page. aide fired, prosecuted, etc etc.

    should jane be taken out of school? no, not in my opinion. it's a learning opportunity; she believed she had the necessary permission because a doctor told her it was ok. her ignorance in this situation doesn't deserve explusion.

    just my opinions
    sharpeimom, VivaLasViejas, Meriwhen, and 3 others like this.
  5. Visit  Pepper The Cat profile page
    2
    OK- first, I am Canadian so am not familiar with HIPAA ( or is it HIPPA - sorry, I get confused)

    But -I would want to know - did Jane ask the pt's permission to take the picture? Why was a picture necessary? Could she just not discuss what the condition was and subesquent treatment? I feel that the technology of phones being able to take pictures has really invaded people's privacy. As someone with a rare medical condition I am fine with students learning more about the disease, but posting pictures is a little bit too invasive for me. I don't know who sees those pictures or what is being done with them.
    Once a picture is taken and sent to another person, we lose all control of that picture. I don't know if I want pictures of me or my medical condition being passed around randomly.
    lindarn and tokmom like this.
  6. Visit  RockinChick66 profile page
    2
    Yes, I believe she violated hippa. Why did she need a picture of the scan? There is no reason a nurse needs to see pictures of the scan. That's the doctors business, not the nurse. No, she should not be expelled from nursing school, as this is a learning experience.
    JustBeachyNurse and lindarn like this.
  7. Visit  Ashley, PICU RN profile page
    4
    I actually disagree. I do not believe this was a HIPAA violation because there was no disclosure of protected health information.
    In order for HIPAA to have been violated, there must be sharing of personally identifiable information without the patient's consent. In this case, there were no identifiers on the picture, and the picture itself (since it does not identify the person) is not protected.

    OP, here is a very detailed explaination of wha HIPAA covers and does not cover. UC Berkeley Committee for Protection of Human Subjects
    You will see that the first section includes a list of the 18 personal identifiers covered under HIPAA. It does on to describe exactly what protected health information (PIH) is, and what it is not. I'll allow you to read it for yourself, but I've coped a few pertinent sentances below.


    List of 18 identifiers
    "1. Names;
    2. All geographical subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code, if according to the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.
    3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older;
    4. Phone numbers;
    5. Fax numbers;
    6. Electronic mail addresses;
    7. Social Security numbers;
    8. Medical record numbers;
    9. Health plan beneficiary numbers;
    10. Account numbers;
    11. Certificate/license numbers;
    12. Vehicle identifiers and serial numbers, including license plate numbers;
    13. Device identifiers and serial numbers;
    14. Web Universal Resource Locators (URLs);
    15. Internet Protocol (IP) address numbers;
    16. Biometric identifiers, including finger and voice prints;
    17. Full face photographic images and any comparable images; and
    18. Any other unique identifying number, characteristic, or code (note this does not mean the unique code assigned by the investigator to code the data)"


    "Also note, health information by itself without the 18 identifiers is not considered to be PHI. For example, a dataset of vital signs by themselves do not constitute protected health information. However, if the vital signs dataset includes medical record numbers, then the entire dataset must be protected since it contains an identifier. PHI is anything that can be used to identify an individual such as private information, facial images, fingerprints, and voiceprints. These can be associated with medical records, biological specimens, biometrics, data sets, as well as direct identifiers of the research subjects in clinical trials."
    In nursing school, we were allowed to copy information from the chart to work on our care plans at home as long as we did not copy down any identifying information, such as name or medical record number. This was not a HIPAA violation because the information could not be used to identify the patient.

    So, in short, unless the instructor could look at the picture of the scan and identify protected health information about the patient, it was not a HIPAA violation. The picture of the scan itself, with no protected health information, is not a violation.
    Last edit by Ashley, PICU RN on Apr 3, '12 : Reason: added information, changed paragraph spacing
    sharpeimom, GrnTea, ckh23, and 1 other like this.
  8. Visit  Esme12 profile page
    0
    Quote from studentontheedge
    so far, everyone has split opinions...

    "jane works in the ed part time as a tech and goes to nursing school. she was working one day when a "once in a lifetime" patient came in with an issue that brought about a head scan that none of the doctors in the ed had seen to date in their 200+ years total of experience.
    jane wanted to take a picture of the scan for educational purposes. she asked the very well respected doctor who was caring for the patient, who had also been the nursing director. the physician agreed happily and told her to make sure the picture she took with her phone did not have any identifying features in it, and jane did as instructed. there were no numbers or letters on the scan that would identify the patient.
    jane was excited to share her great scan with her instructor who she trusted in the educational setting. she had not shown anyone, and in private, she showed her instructor while telling the instructor about what she had learned. in a very concerned tone of voice, the instructor said to delete it immediately and she had violated hipaa."

    did jane violate hipaa law? or is this a grey area untouched by the law? should jane be taken out of nursing school?
    to quote ashley from yesterday.......

    yes, it is a hipaa violation. hipaa requires patient consent for the release of identifiable information, including patient photography beyond the purposes of billing and treatment. patient photography, videotaping, and other imaging (updated)
    http://allnurses.com/general-nursing...744-page3.html

    yesterday's thread was another good hipaa thread.....http://allnurses.com/general-nursing...st-692744.html
  9. Visit  Pneumothorax profile page
    0
    Quote from esme12
    to quote ashley from yesterday.......

    yes, it is a hipaa violation. hipaa requires patient consent for the release of identifiable information, including patient photography beyond the purposes of billing and treatment. patient photography, videotaping, and other imaging (updated)
    http://allnurses.com/general-nursing...744-page3.html

    yesterday's thread was another good hipaa thread.....http://allnurses.com/general-nursing...st-692744.html
    but it was a picture of a picture. did the patient sign consent for the mri/ct to be taken?

    im asking a legit question.
  10. Visit  Ashley, PICU RN profile page
    1
    I think there is a difference between taking a picture of someone's face (yesterday's thread) and taking a picture of a scan, such as an MRI scan or a CT scan that has no identifiable information.

    Here's a few similar examples:

    A patient has a very rare abnormal heart rhythm. I want to share it with my nursing class, so I get a copy of the EKG and cut out just the rhythm strip with no name or other information, just the strip. While that EKG strip may be unique to that one patient, the strip alone cannot be used to identify the patient, so it's not a HIPAA violation.

    Say I have a very rare brain tumor. Someone takes a picture of my MRI scan with no identifiable information, just the scan. This is not a HIPAA violation either because the image itself is not able to identify me. If someone on the bus has a copy of that scan and they see me sitting next to them they will have no way of knowing that the scan came from me.

    Full-face photographic images are protected under HIPAA as one of the 18 identifiers. Test results that contain none of the 18 identifiers are not considered protected health information and therefore not covered under HIPAA.
    GrnTea likes this.
  11. Visit  psu_213 profile page
    0
    She probably should have gotten the pt's permission--but generally I don't think this was HIPAA violation if she removed all identifiers. In my mind, just having a 'unique' head CT, does not make it identifiable for a given pt--i.e. someone looking at the CT will not conclude "oh, that has to be Sally Smith." Also, several textbooks/journals have radiology images in them--what type of permission is required from the pt if an author want to put a radiology image in a book (for the record, I don't know the answer to the question, but if the pt gives permission, it is obviously not a HIPAA violation if identifiers are removed)?

    Not really related to the ethical question--why would a student in nursing school (not NP/CNRA,etc. school) feel the need to take a photo of the CT for the class? Would I find it interesting? Yeah, but I'm a dork like that. I can hear people from my nursing class right now: "This is dumb," "What am I looking at, and why do I need to see this?" "What a waste of time." Given the scope of nursing school, there is no real need to display this photo to class, and no reason for "Jane" to even put herself in the way of the HIPAA train.
  12. Visit  ckh23 profile page
    1
    Nope. There are no patient identifiers. Besides there are millions of pictures used in various teaching and education. Just check out a M&M conference.
    GrnTea likes this.
  13. Visit  StudentOnTheEdge profile page
    0
    Great conversation! The next question to be asked would be if the school should tell the place of employment about the occurance? If they believe or dont believe that hipaa was violated, do they have the right to call and get the student and possibly the physician fired?
  14. Visit  Ashley, PICU RN profile page
    4
    First, realize that physicians aren't usually employed by the hospital. They are granted privileges to practice there. Physicians have a choice about where they want to send and treat their patients. So it's highly unlikely that the hospital would revoke the "respected" physicians privileges because all they would really be doing is losing patients and money.

    Second, since this wasn't a HIPAA violation there would be no point to notifying the hospital. It would just create trouble and make the school look like they are trying to start trouble. I can imagine that conversation:
    "I just wanted to let you know that Tech So and So took a picture of a test result, with the permission of Dr. What's His Name and showed her school instructor."
    "Oh, was there any a patient in the picture or any patient information on the picture?"
    "No."
    "Oh, did the patient complain?"
    "No."
    "Was the image posted on the internet?"
    "No. Nobody saw it except the instructor and the employee has deleted it."
    "Okay. Goodbye."

    Hospital administration is really just concerned with their bottom line. If the patient isn't complaining or threatening to sue, it's not going to matter to them too much. They certainly aren't going to offend a prominent physician and risk losing their patients. They aren't going to want to have to spend the money to hire and train a new tech for an issue that isn't illegal and isn't affecting the patient.
    juzme, sharpeimom, GrnTea, and 1 other like this.
  15. Visit  Esme12 profile page
    3
    I am still not so sure this is not a HIPAA violation. I also have never heard a MD say it was OK to take a picture of an x-ray to show anyone. The rareness of the disease itself can be the identifier.

    For example......Lets say I took care of someone who had a foreign object in the rectum and perforated their bowel. When the x-ray returned it showed the largest carrot I have ever seen inside someone abdomen. If I took a picture of this and showed it to my students and the family overheard or saw this picture that knew the gentlemen they would know who the x-ray was from. When the family gets upset and complains that they heard this, it can be viewed as a HIPAA violation as it is not the need to know basis for the care of the patient.....The "Need to Know rule" is an important factor in determining HIPAA violations. HIPAA specifically mentions "biometric identifiers" as finger prints, voice prints, full face, and ANY comparable photo/digital images of an individual. Possibly making x-rays PHI. (protected health information)

    The individual needs to be given the opportunity to agree or object and give consent. PHI may be released to certain entities such as police without consent of the individual but it is limited. There are a few other reason that PHI can be released without consent, like the CDC, but a nursing student with a phone camera and a rare disease isn't one of them. This doesn't fit the "minimum necessary" released for a strict "need to know".

    Having a rare disorder myself, that affects only 10-20 people per million, that involves a very distinct rash and discoloration of my skin. I am asked, or sign a consent, every time someone wants a picture and if they may release it for books and studies. If a picture of a picture was taken...without my permission, on a cell phone to share with other people.....however good intended.....I would be very upset and feel that I have been violated. If found, when investigated, that it was not HIPAA.....I would still sue for invasion of my privacy.........due to the fact it was within the confines of the hospital where the expectation of privacy is assumed.

    Now if you sneak a picture at the mall there is nothing I can do because the assumption of privacy isn't there.

    I still believe it is a violation of HIPAA because the x-ray is PHI reguardless of the rarity of the disease. School throw in the rarity of the disease to lure you into thinking it's ok, but it is not.

    I hope this helps.
    grpman, juzme, and nowim clean like this.


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