Policy # & Policy Title: Effective Date: LR.05.029 Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment 11/08/2016 Policy Photographing, filming, or recording in any way of patients1, staff members or Thompson Health data, equipment or property by patients, visitors, staff or others is prohibited except as described in this policy. Photographing, filming, or recording an image of a patient (for purposes of this policy, hereinafter referred to as “recording”) can be useful for many purposes. However, in order to preserve the privacy and confidentiality of our patients and staff, recordings may only be made for permitted purposes, by authorized individuals. Written consent must be obtained from a patient prior to recording any patient image taken for internal organizational uses such as education of workforce members or quality assurance. Consent is not required when an image is used for the sole purpose of treatment, diagnosis or identification of the patient. Consent may be obtained from a patient’s personal representative when the patient is unable to consent. Photographs, videotapes, electronic or digital image transmissions and radiological images of patients taken in the course of medical care are privileged. Images of patients cannot be published or otherwise disclosed outside of URMC and Affiliates, including Thompson Health, without the patient’s express written authorization. If the images can identify the patient, the authorization must also be in compliance with the federal Health Insurance Portability and Accountability Act privacy regulations (HIPAA), except as permitted under URMC and Affiliates’ HIPAA policies and procedures. Description A. Recording of Patients – In Situations Where Consent Is NOT Required 1. Patient consent is not required for recording patient images in the direct course of providing medical care, consultation or treatment to that patient. However, if the provider believes that the images may be published, displayed or used for other purposes in the future, a HIPAA-compliant authorization should be obtained in advance of the recording. 2. Consent of the patient, parent or other legal representative is not required when recording patients in the course of care and treatment for suspected child abuse. 1 Patients include residents at the M.M. Ewing Continuing Care Center. Page 1 of 5 Policy # & Policy Title: Effective Date: LR.05.029 Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment 11/08/2016 Page: 2 of 5 3. Recordings taken for clinical purposes (treatment, identification, etc.) should be taken by a Thompson Health authorized workforce member, preferably using an encrypted camera. 4. Anyone involved in the production of recordings for Thompson Health who is not already bound by the F.F. Thompson Hospital/M.M. Ewing Continuing Care Center’s patient privacy policies must sign a confidentiality statement to protect the patient’s identity and protected health information. Additionally, those involved in the production of recordings for the M.M. Ewing Continuing Care Center (“CCC”) must take training on abuse and neglect prevention prior to making any recordings. 5. Whenever possible, Surgical Pathology should be asked to photograph specimens from the Operating Room or other procedural areas when this is required. This can take place either during the procedure if it does not interfere with surgery, or upon arrival of the specimen in Surgical Pathology. 6. An identifiable image of a patient is protected health information and must be treated accordingly. This includes assuring the security of the image on the camera or other capture device to protect the privacy of the patient. Use of encrypted cameras is preferred. As soon as possible after recording the image, the image should be downloaded to a file on a secure network drive and the image deleted from the device. B. Recording of Patients – In Situations Where Consent/Authorization IS Required 1. When recording is for internal purposes such as education of staff or performance improvement activities, the patient or personal representative’s written consent should be obtained (form SH 1411 MR, attached). 2. Any external disclosure of a patient image (e.g. for external conference presentation, research, academic uses, marketing, to news or other media, etc.) requires that a HIPAA compliant authorization (form SH48GP, attached) be signed by the patient or personal representative as the image may contain protected health information. A copy must be provided to the patient. The authorization must be maintained in the patient’s medical record for six years beyond the effective date. 3. If there may be an external disclosure of a patient recording, the consent must also include an explanation of how the recording will be used. 4. If a recording may be used for an internal or external purpose other than identification, diagnosis or treatment of the patient, the consent must explain that the patient has the right to withhold consent or request cessation of the production of the recording, if consent is given, and that Thompson Health Policy # & Policy Title: Effective Date: LR.05.029 Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment 11/08/2016 Page: 3 of 5 will accommodate the patient if the patient chooses to withhold or rescind consent. 5. If a patient or a personal representative is unable to give written consent before recording, the patient’s image cannot be used until and unless consent is obtained, except if the sole use of the image is for the treatment, diagnosis or identification of the patient. 6. An identifiable image of a patient is protected health information and must be treated accordingly. This includes assuring the security of the image on the camera or other capture device to protect the privacy of the patient. As soon as possible after recording the image, the image should be downloaded to a file on a secure network drive and the image deleted from the device. 7. Recordings of patients taken for non-clinical purposes other than education and performance improvement (such as for promotion) should be coordinated through Corporate Communications and Legal & Regulatory Affairs. Corporate Communications and Legal & Regulatory Affairs will ensure that the appropriate authorizations are obtained from patients who will be recorded and that the recordings are not demeaning or humiliating. 8. Recordings may never be taken of a patient, or used in any manner, that demeans or humiliates the patient regardless of whether the patient or personal representative consented to the recording. 9. Workforce members are prohibited from recording any patients except as specifically permitted under this policy. 10. Anyone involved in the production of recordings for Thompson Health who is not already bound by the hospital/CCC’s patient privacy policies must sign a confidentiality statement to protect the patient’s identity and protected health information. Additionally, those involved in the production of recordings for the CCC must take training on abuse and neglect prevention prior to making any recordings. C. Recording of Patients or Staff by Patients or Visitors 1. Patients may allow family members or visitors to photograph, film or record (for purposes of this policy, hereinafter referred to as “record”) the patient while in the hospital/CCC, subject to the specific limitations on this privilege described in paragraph C.2 below, and subject to any restrictions that may be imposed by hospital/CCC staff related to patient safety and/or disruption of patient care. The hospital/CCC expressly reserves the right to suspend this privilege if in the judgment of hospital/CCC staff the care of any patient may be jeopardized and/or any time hospital operations may be impaired. Whether or not the request is related to a care issue, the staff member receiving the Policy # & Policy Title: Effective Date: LR.05.029 Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment 11/08/2016 Page: 4 of 5 request should seek assistance through his/her manager or other appropriate resource to evaluate and develop an appropriate response to the request. Patients, family members and visitors involved in requests to record a patient should be informed of the rules applicable to this privilege. 2. If a patient requests a family member or visitor to record the patient, the recording may take place provided the following conditions are met: a. Staff may not be recorded without their specific knowledge and permission. b. Recording is not to take place when staff is providing treatment (other than noted in C.2.d below), or having a discussion with any patient including other patients in the room or area, such as in a semi-private room. c. Patients, family or visitors may not record any other patients without their specific knowledge and permission, or authorization where required. d. Specific rules apply to request the recording of obstetrical and newborn infant patients. If a maternal patient wishes to have a family member or support person record her and her newborn during the perinatal period, including during labor and delivery, it shall be permitted regardless of the type of delivery, provided the patient agrees and subject to the limitations of sections a, b and c of this paragraph. However, the anesthesia evaluation interview, anesthesia block procedures and all aspects of general anesthesia in OB may not be recorded. As a general rule, family and visitors approved by the patient will be permitted to record during vaginal delivery procedures, and during cesarean delivery procedures with spinal or epidural anesthesia. However, any member of the OB health care team has the right to direct the location of the activity, and to limit or suspend the activity. Any member of the OB health care team may request and if necessary direct that recording be stopped if the process is interfering with or threatening the safe care of the patient or her newborn, or disruptive of hospital/CCC operations. 3. To the extent staff is aware of a particular recording being made, staff may not permit recordings to be taken of a patient, or used in any manner, that demeans or humiliates the patient regardless of whether the patient or personal representative consented to the recording. D. Recording of Staff and other Non-Clinical Images of Thompson Health 1. To protect the privacy rights of our workforce members, all patients, visitors and staff members are prohibited from recording members of the workforce without their express permission while they are on the hospital/CCC premises or working off-site. Employees may photograph areas of the Thompson Policy # & Policy Title: Effective Date: LR.05.029 Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment 11/08/2016 Page: 5 of 5 Health that are public spaces, and public events, but are prohibited from recording other areas of the Thompson Health premises, hospital/CCC equipment, or the hospital/CCC environment unless otherwise authorized under this policy. 2. Recordings of staff while on Thompson Health premises, hospital/CCC equipment, or the hospital environment for non-clinical purposes other than education and performance improvement should be coordinated through Corporate Communications, which will ensure that the appropriate authorizations are obtained. E. General Provisions 1. Nothing in this policy will be construed to prevent Thompson Health from using security monitoring equipment. 2. Violations of any aspect of this policy by any member of the workforce may have serious employment consequences. 3. Any staff member who witnesses a violation of this policy or has a question regarding the policy or determining whether a request to record a patient may compromise patient dignity, privacy or confidentiality should contact Thompson Health’s Privacy Officer, who can be reached by calling 396-6714. Attachments: Form SH 1411 MR – Consent for Photography, Filming or Recording Form SH48GP – Authorization for Release of Medical Information/Image to the General Public Vendor Confidentiality Agreement Non-Patient Consent for Photographing, Filming or Recording References: Committee Review: Joint Commission: NYSDOH: Other References: Review Cycle: Author: Policy’s Dept.: Supersedes: Origin. Date: Applies To: Department List: Approved By: N/A Joint Commission RI.01.03.03 N/A CMS Mandate S&C: 16-33-NH; HIPAA Privacy Regulations, 45 CFR164.512; HIPAA Privacy Policy OP7.1 and OP16 24 Months Elizabeth Talia (Vp Legal&Reg Affairs/Coun) 03.930 - Legal & Regulatory Affairs LR.05.029 & IM.03.015.01 Dated: 12/01/2014 & 3/23/10 4/1/2003 FFTH, MMECCC All Amy Daly (Vp, Long Term Care), Lalena Symonds (Legal & Compliance Admin), Michael Stapleton (President Ceo Ffths)