Is your pathologist serious about patient confidentiality?

This article examines the manner in which pathology reports are delivered to South African physicians and raises concerns regarding patient confidentiality. The importance of an audit between ordered and received pathology tests is explored.

A strong argument is made for secure, encrypted, electronic transmission to replace the sometimes cavalier approach to patient privacy.

Confidentiality of pathology reports has always been important: the advent of HIV has merely highlighted an issue that should have been addressed years ago.

Very few practices have an audit process whereby each ordered test is ticked off once returned. Most doctors assume that all ordered tests will be returned and have no way of monitoring missing reports (sometimes found weeks later under the courier's bakkie seat). If that test were a positive screening test, done as part of a routine yearly physical, often neither doctor nor patient realises that something is missing--sometimes with catastrophic results.

In such cases, is the ordering doctor or the laboratory liable?

Some years ago, in my own practice I did a screening test for Down's syndrome. The test was not returned and I didn't have any system that would alert me to the fact that I had not seen that particular result. It was positive. The patient returned for her next antenatal visit 4 weeks later. This prompted me to look for the result of her Down's screen. She was now too late to be offered therapeutic termination.

Pathology reports are generally delivered by courier, fax, e-mail and, recently, by an encrypted, secure, auditable electronic system similar to the more familiar on-line banking model.

There are international guidelines concerning these delivery methods. (1)

Faxes

Generally one should not fax sensitive personal information. If faxing is the only timely method available, the following precautions are required:

* Rules concerning the type of personal information that can be faxed from the laboratory must be documented. The laboratory must check regularly to confirm that employees are following the rules.

* The fax machine must be located in a secure area and access controlled to prevent unauthorised persons viewing faxed information. When faxing sensitive information, the machine must be monitored during the faxing process.

* Phone ahead to confirm the practice fax number before sending personal information. Confirm the recipient's security arrangements for receiving faxes. Ask the intended recipient to call as soon as possible to confirm receipt of the fax.

* Use encryption technology to fax sensitive personal information.

Transporting of reports by courier

It is essential to ensure that the courier company implements the following security safeguards:

* Physical security in offices and vehicles.

* Restricted employee access to personal information. Sealed envelopes.

* Staff must sign confidentiality agreements.

* Ensure that drivers are insured.

* Set driver guidelines and policy to ensure that personal information is kept secure while in the vehicle.

* Ensure that the courier company tracks the shipment and collects the signature of the receiver when the delivery is made.

* The sender should record an itemised description of the documents being transported in case of disagreement about what documents were received, or in case missing documents need to be identified.

Practically, we are all aware that this does not happen, but is it reasonable to keep ignoring the potential to harm our patients when there is a better way?

E-mail

Unencrypted e-mail is an unacceptable means of communicating confidential patient information (think of a post card). Even encrypted delivery through commercial Internet service providers (ISPs) can be a hit-and-miss affair subject to the vagaries of the anti-spam policies of various ISPs. The poor security of PDF attachments (even encrypted) merely adds to the problems. (2)

Electronic results

These may be sent with the proprietary system of the laboratory or by means of an independent transport hub. The independent hub has certain advantages:

* Data are carried from all laboratories in one system; the practitioner is not tethered, in perpetuity, to one laboratory.

* Other clinical data (collegial communication, radiology reports) are carried by the same system.

* The doctor has one number that can be called for help and the staff member answering that call has been trained (and has the tools) to solve the problem quickly.

* There is one interface for practice management and hospital integration.

* All historic clinical data are securely archived in one place and are accessible using a web browser (on-line banking model). A doctor can search by patient and instantly see all laboratory information, all imaging results and all consultations for that patient. This is powerful stuff!

* There is no reliance on commercial ISPs--this system allows audited and confirmed delivery to the end destination.

With the current, worldwide emphasis on patient privacy coupled with the ability of electronic ordering and delivery systems to audit that all ordered tests are returned (and to raise an alert if this does not happen) the 'old way' is increasingly difficult to defend.

References

(1.) The Office of the Information & Privacy Commissioner for British Columbia, Canada.

(2.) http://www.password-crackers.com/crack/guapdf.html (last accessed).

DARRYL GARTHVINE, MB ChB, FRCSC Medical Director, Bluebird, Intel MS (Pty) Ltd, Cape Town