Que. What obligation does medical professional have about sharing information?

Ans. Confidentiality is one of the core duties of medical practice. It requires health
care providers to keep a patients personal health information private unless consent to
release the information is provided by the patient.
Why is confidentiality important?
Patients routinely share personal information with health care providers. If the
confidentiality of this information were not protected, trust in the physician-patient
relationship would be diminished. Patients would be less likely to share sensitive
information, which could negatively impact their care. Why is confidentiality
important?
Creating a trusting environment by respecting patient privacy encourages the patient
to seek care and to be as honest as possible during the course of a health care visit.
(See also Physician-Patient Relationship.) It may also increase the patients
willingness to seek care. For conditions that might be stigmatizing, such as
reproductive, sexual, public health, and psychiatric health concerns, confidentiality
assures that private information will not be disclosed to family or employers without
their consent.
What does the duty of confidentiality require?
The obligation of confidentiality prohibits the health care provider from disclosing
information about the patient's case to others without permission and encourages the
providers and health care systems to take precautions to ensure that only authorized
access occurs. Appropriate care often requires that information about patients be
discussed among members of a health care team; all team members have authorized
access to confidential information about the patients they care for and assume the duty
of protecting that information from others who do not have access. Electronic medical
records can pose challenges to confidentiality. In accordance with the Health
Information Portability and Accountability Act of 1997 (HIPAA), institutions are
required to have policies to protect the privacy of patients electronic information,
including procedures for computer access and security.
What if a family member asks how the patient is doing?

While there may be cases where the physician feels naturally inclined to share
information, such as responding to an inquiring spouse, the requirements for making
an exception to confidentiality may not be met. If there is not explicit permission from
the patient to share information with family member, it is generally not ethically
justifiable to do so. Except in cases where the spouse is at specific risk of harm
directly related to the diagnosis, it remains the patient's (and sometimes local public
health officers), rather than the physician's, obligation to inform the spouse.
What other kinds of disclosures are inappropriate?
Unintended disclosures may occur in a variety of ways. For example, when pressed
for time, providers may be tempted to discuss a patient in the elevator or other public
place, but maintaining privacy may not be possible in these circumstances. Similarly,
extra copies of handouts from teaching conferences that contain identifiable patient
information should be removed at the conclusion of the session in order to protect
patient privacy. And identifiable patient information should either be encrypted or
should not be removed from the security of the health care institution. The patient's
right to privacy is violated when lapses of this kind occur.
When can confidentiality be breached?
Overriding concerns can lead to the need to breach confidentiality in certain
circumstances.
Exception 1: Concern for the safety of other specific persons
Access to medical information and records by third parties is legally restricted. Yet, at
the same time, clinicians have a duty to protect identifiable individuals from any
serious, credible threat of harm if they have information that could prevent the harm.
The determining factor is whether there is good reason to believe specific individuals
(or groups) are placed in serious danger depending on the medical information at
hand. An example is homicidal ideation, when the patient shares a specific plan with a
physician or psychotherapist to harm a particular individual.
The California Tarasoff case exemplifies the challenges providers face in protecting
confidentiality. In that case a graduate student, Prosinjit Podder, disclosed to a
counselor affiliated with Berkeley University that he intended to obtain a gun and
shoot Tatiana Tarasoff. Dr. Moore, the psychologist, found Podders threat credible.

Dr. Moore then faced dual obligations: protect Tatiana Tarasoff from harm and protect
Mr. Podders confidentiality. Dr. Moore sent a letter to campus police about the threat.
They spoke to Mr. Podder, told him to stay away from Tatiana, but determined he was
not a danger to her. He later stalked, stabbed and killed Tatiana. Tatianas parents sued
campus police and the universitys health service for failure to warn Tatiana. The
lower court refused to hear the case, claiming that Dr. Moore had an obligation to
protect Podders confidentiality. Tarasoffs parents appealed and the California
Supreme Court ruled that, the discharge of this duty may require the therapist to take
one or more of various steps. Thus, it may call for him to warn the intended victim, to
notify the police, or to take whatever steps are reasonably necessary under the
circumstances. (Ref. Tarasoff case).
The implication of this ruling is that a duty to warn third parties of imminent threats
trumps a duty to protect patient confidentiality, however, it is usually difficult for a
therapist or health care provider to accurately ascertain the seriousness and imminence
of a threat. Tarasoff has subsequently been interpreted to endorse the providers duty
to warn when a patient threatens an identifiable victim. Ethically, most would agree
that a duty to warn an innocent victim of imminent harm overrides a duty to
confidentiality, but these cases are rare and judgment calls of this sort are highly
subjective. Hence, the duty to maintain confidentiality is critical, but may be
overridden in rare and specific circumstances.
Exception 2: Legal requirements to report certain conditions or circumstances
State law requires the report of certain communicable/infectious diseases to the public
health authorities. In these cases, the duty to protect public health outweighs the duty
to maintain a patient's confidence. From a legal perspective, the State has an interest
in protecting public health that outweighs individual liberties in certain cases. For
example, reportable diseases in Washington State include (but are not limited to):
measles, rabies, anthrax, botulism, sexually transmitted diseases, and tuberculosis.
Suspected cases of child, dependent adult, and elder abuse are reportable, as are
gunshot wounds. Local municipal code and institutional policies can vary regarding
what is reportable and standards of evidence required. Stay informed about your state
and local policies, as well as institutional policies, governing exceptions of patient
confidentiality.
A Test for Breach of Confidentiality

In situations where you believe an ethical or legal exception to confidentiality exists,

ask yourself the following question: will lack of this specific patient information put
another person or group you can identify at high risk of serious harm? If the answer to
this question is no, it is unlikely that an exception to confidentiality is ethically (or
legally) warranted. The permissibility of breaching confidentiality depends on the
details of each case. If a breach is being contemplated, it is advisable to seek legal
advice before disclosure.
What are the confidentiality standards regarding adolescents?
In many states adolescents may seek treatment without the permission of their parents
for certain conditions, such as treatment for pregnancy, sexually transmitted
infections, mental health concerns, and substance abuse. Familiarize yourself with
state and local laws, as well as institutional policies, regarding adolescents and
healthcare.

What makes document and records management different?

Document management and records management do share a goal of business continuity. Shortcomings in either practice
can contribute to the downfall of the entire organization. However, when both document and records management work
toward their goals (efficiency and compliance), the longevity of the organization becomes more secure.
These terms differ in three main ways:
1.

Goal: the purpose of each practice.

2.

Information: the content involved in each practice.

3.

Methodology: the way each practice is performed.

Lets break these distinctions down further:

1. Goal
The goal of document management is efficiency. Approving documents faster, reducing manual data entry and automating
recurring tasks are some of the many functions of document management that work toward this goal.
On the other hand, the goal of records management is compliance. A well-oiled records management system helps
organizations avoid penalties when regulators, auditors and other governing bodies come calling.

2. Information
The information of document management is comprised of transient content. Invoices are signed and then sent off to the
next approver; older drafts are discarded for revised ones; forms pass from submitter to reviewer and so on.

Meanwhile, the information of records management is comprised of historical content. The status of a document is
determined by different phases of the records lifecycle, as shown below:

Different phases of the records lifecycle

The various drafts, versions and copies of active documents are consolidated into what is only essential for the purpose of
compliance.
In short, workers need documents to do their jobsbut they need records to prove they did their jobs.

3. Methodology
The methodology of document management is content-driven. As mentioned above, content is the catalyst for all
document-related activity. Therefore, document repositories are usually organized with the needs of general users in mind:
finding documents by keyword or title, keeping all documents together by employee or project, etc.
In contrast, the methodology of records management is context-driven. Records managers care more about document
types (insurance records, employment applications etc.) than the words written on the actual documents. As a result,
retention schedules are the catalyst for records-related activity, as different types of records must be kept for different lengths
of time, and under different conditions.

Que. What is the obligation of the state to

provide healthcare ?
Ans. 1 One of the most important roles government plays in contemporary society is

protecting people from unsafe products and environmental conditions. Although the
Supreme Court has rejected calls to read the Constitution of the United States to
include positive rights, this articles central claim is that the Supreme Courts
rejection of the Medicaid expansion in the Patient Protection and Affordable Care Act
makes sense only if the Constitution is understood as requiring government to
provide for the health, safety and welfare of its citizens. Its not that Chief Justice
Roberts intended this implication, but if states did not feel obligated to provide, in
this instance, health care, they would not have felt coerced, as the Courts opinion
concluded they were, into accepting the Medicaid expansion. Congress violates this
understanding when it enacts irrational exceptions to health, safety and welfare
programs, such as the 1975 Proxmire Amendment which limits the FDAs authority
to regulate vitamins and supplements. Even if courts do not strike down irrational
exceptions to health, safety and welfare laws, their inconsistency with governments
basic obligation to its citizens should make legislators and regulators hesitate before
enacting or promulgating them.

Ans 2.

I have to admit I often have found the language of healthcare rights off-putting. Yet the idea of healthcare as a right is

usually pitted against the idea of healthcare as a privilege. Given that choice, Ill circle right every time.

Still, when people claim something as a right, they often sound shrill and demanding. Then someone comes along to remind us
that people who have rights also have responsibilities, and the next thing you know, were off and running in the debate about
healthcare as a right vs. healthcare as a matter of individual responsibility.
As regular readers know, I believe that when would-be reformers emphasize individual responsibilities, they shift the burden to the
poorest and sickest among us. The numbers are irrefutable: low-income people are far more likely than other Americans to become
obese, smoke, drink to excess and abuse drugs, in part because a healthy lifestyle is expensive, and in part because the stress of
being poorand having little control over your lifeleads many to self-medicate. (For evidence and the full argument, see this
recent post). This is a major reason why the poor are sicker than the rest of us, and die prematurely of treatable conditions.
Those conservatives and libertarians who put such emphasis on individual responsibility are saying, in effect, that low-income
families should learn to take care of themselves.
At the same time Im not entirely happy making the argument that the poor have a right to expect society to take care of them. It
only reinforces the conservative image (so artfully drawn by President Reagan) of an aggrieved, resentful mob of freeloaders
dunning the rest of us for having the simple good luck of being relatively healthy and relatively wealthy. We didnt make them poor,
libertarians say. Why should they have the right to demand so much from us? Put simply, the language of rights doesnt seem
the best way to build solidarity. And I believe that social solidarity is key to improving public health.

Biopotentials and ionic currents

The voltage differences which exist between separated points in living cells, tissues, organelles, and orga
nisms are calledbiopotentials. Related to these biopotentials are ionic charge transfers, or currents, that
give rise to much of the electricalchanges occurring in nerve, muscle, and other electrically active cells. El
ectrophysiology is the science concerned withuncovering the structures and functions of bioelectrical syst
ems, including the entities directly related to biological potentialsand currents. According to their function,
these structures are given descriptive names such as channels, carriers,ionophores, gates, and pumps.
The potential difference measured with electrodes between the interior cytoplasm and the exterior aqueo
us medium of theliving cell is generally called the membrane potential or resting potential (ERP). This pote
ntial is usually in the order ofseveral tens of millivolts and is relatively constant or steady. The range of ER
P values in various striated muscle cells ofanimals from insects through amphibia to mammals is about 50 to 100 mV (the voltage is negative inside with respect tooutside). Nerve cells show a similar range in s
uch diverse species as squid, cuttlefish, crabs, lobsters, frogs, cats, andhumans. Similar potentials have b
een recorded in single tissue-culture cells.

Biopotentials arise from the electrochemical gradients established across cell membranes. In most animal
cells, potassiumions are in greater concentration internally than externally, and sodium ions are in less co
ncentration internally thanexternally. Generally, chloride ions are in less concentration inside cells than out
side cells, even though there are abundantintracellular fixed negative charges. While calcium ion concentr
ation is relatively low in body fluids external to cells, theconcentration of ionized calcium internally is much
lower (in the nanomolar range) than that found external to the cells.

Sodium pump
Measurements of ionic movements through cell membranes of muscle fibers by H. B. Steinbach and by L.
A. Heppel in thelate 1930s and early 1940s found that radioisotopically labeled sodium ion movement thr
ough the cell membrane from insideto outside seemed to depend upon the metabolism of the cell. I. M. Gl
ynn showed that the sodium efflux from red cellsdepended on the ambient glucose concentration, and A.
L. Hodgkin and R. D. Keynes demonstrated in squid and Sepiagiant axons that the sodium efflux could be
blocked by a variety of metabolic inhibitors (cyanide, 2,4-dinitrophenol, andazide). It was proposed that a
metabolic process (sodium pump) located in the cell membrane extruded sodium from the cellinterior agai
nst an electrochemical gradient. P. C. Caldwell's experiments on the squid's giant axon in the late 1950sin
dicated that there was a close relation between the activity of the sodium pump and the intracellular prese
nce of high-energy compounds, such as adenosine triphosphate (ATP) and arginine phosphate. Caldwell
suggested that thesecompounds might be directly involved in the active transport mechanism. Evidence b
y R. L. Post for red cells and byCaldwell for the giant axon also suggested that there was a coupling betw
een sodium extrusion and potassium uptake.Convincing evidence has been presented that ATP breakdo
wn to adenosine diphosphate and phosphorus (ADP + P)provides the immediate energy for sodium pump
ing in the squid giant axon. It seems that the sodium pump is a sufficientexplanation to account for the hig
h internal potassium and the low internal sodium concentrations in nerve, muscle, and redblood cells. Se
e Absorption (biology), Cell permeability

Channels
In living cells there are two general types of ion transport processes. In the first, the transported ionic spe
cies flows downthe gradient of its own electrochemical potential. In the second, there is a requirement for
immediate metabolic energy. Thisfirst category of bioelectrical events is associated with a class of molecu
les called channels, embedded in living cellmembranes. It is now known that cell membranes contain ma
ny types of transmembrane channels. Channels are proteinstructures that span the lipid bilayers forming t
he backbones of cell membranes. The cell membranes of nerve, muscle, andother tissues contain ionic c
hannels. These ionic channels have selectivity filters in their lumens such that in the open stateonly certai
n elementary ion species are admitted to passage, with the exclusion of other ion species. See Cell
membranes
There are two general types of channels, and these are classified according to the way in which they resp
ond to stimuli.Electrically excitable channels have opening and closing rates that are dependent on the tra
nsmembrane electric field.Chemically excitable channels (usually found in synaptic membranes) are contr
olled by the specific binding of certainactivating molecules (agonists) to receptor sites associated with the
channel molecule.
Calcium channels are involved in synaptic transmission. When a nerve impulse arrives at the end of a ner
ve fiber, calciumchannels open in response to the change in membrane potential. These channels admit c
alcium ions, which act on synapticvesicles, facilitating their fusion with the presynaptic membrane. Upon e

xocytosis, these vesicles release transmittermolecules, which diffuse across the synaptic cleft to depolariz
e the postsynaptic membrane by opening ionic channels.Transmitter activity ceases from the action of sp
ecific transmitter esterases or by reabsorption of transmitter back intovesicles in the presynaptic neuron.
Calcium channels inactivate and close until another nerve impulse arrives at thepresynaptic terminal. Thu
s biopotentials play an important role in both the regulation and the genesis of synaptictransmission at the
membrane channel level.
Ionic currents flow through open channels. The ion impermeable membrane lipid bilayer acts as a dielectr
ic separating twohighly conductive salt solutions. Ionic channels have the electrical property of a conducta
nce between these solutions. Themembrane conductance at any moment depends on the total number of
channels, the type of channels, the fraction ofchannels found in the open state, and the unit conductance
s of these open channels. The most common channels directlygiving rise to biopotentials are those admitt
ing mainly sodium ions, potassium ions, chloride ions, or calcium ions. Thesechannels are named after th
e predominant charge carrier admitted in the open state, such as potassium channels. It is nowknown tha
t there are charged amino acid groups lining the channel lumen that determine the specificity of the chann
el forparticular ions. These selectivity filters admit only ions of the opposite charge.
Hodgkin and A. F. Huxley proposed in 1952 that there were charged molecular entities responsible for the
opening andclosing of the ionic conductance pathways. These structures had to be charged to be able to
move in response to changingelectrical forces when the membrane voltage changed. Any movement of th
e gating structures would require a movement ofcharge and hence should have a detectable component
of current flow across the membrane. It was not until 1973 that theexistence of a gating current in squid a
xon sodium channels was demonstrated, and gating currents and their significancebecame a lively endea
vor in membrane biophysics.