Q: A new patient became abusive after I refused to prescribe narcotics for a back injury that he claimed but was undocumented and undetectable. He stormed out. Then in the morning, we came in to find an expletive spray-painted across the front window. We know it was him because he called to gloat about it. He said that we couldn’t turn him in because “you can’t tell on a patient.” What can I do?

A: You can call the police. What he meant by “telling” on a patient could refer to doctor-patient privilege or to a doctor’s duty of confidentiality.

Privilege does not apply because that refers to the ability of the patient to prevent you from testifying in a legal proceeding about medical knowledge about them that you gained while treating them. His phone confession is neither medical nor part of treatment.

HIPAA does not bar you either. In fact, it actually allows you to reveal personal health information (PHI) to the police under these exceptions:

• Covered entities may reveal PHI about a suspected perpetrator of a crime when the report is made by a victim who is a member of the covered entity’s workforce. This act of vandalism was an attack directed to all of the office staff.
• Covered entities may reveal PHI that is believed to be evidence of a crime that occurred on the premises, which is exactly what happened when he trespassed and then defaced your building.

As always when PHI is released without an authorization or other valid permission, these exceptions are allowed only when release of the PHI is necessary for this purpose. In this case, that would be his name and confirming that he was your patient. If the police ask why he would do this, you can say that you denied him a prescription that he wanted. Do not volunteer details about his history or physical examination. If this ripens into a case, the district attorney will get a proper subpoena or order for your records, and then you can give the medical details.

You can mention that he confessed the vandalism since, just as for privilege, that is a non-medical statement and so not shielded by HIPAA.

By the way, although it is not a medical confidentiality issue, if this does go to court his confession can come in as an exception to the Hearsay Rule because it is a statement against penal interest (ie, a statement that will help get him convicted).