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Documenting the Undocumented

A recent investigation raises questions about illegal immigrants' access to health care.

The immigration debate isn't just on Capitol Hill; documentation woes are hitting home--and hospitals--as well.

Recently, a North Carolina judge ordered the release of medical records for an investigation involving an undocumented immigrant. The woman allegedly used a deceased person's Social Security number to obtain medical care, a crime more commonly known as medical identity theft. But in addition to serving as evidence for criminal charges, the medical record also raises a red flag for deportation because the woman has no documented permission to reside in the country.

While lawmakers have long been grappling over immigration issues, this case draws public health into the mix. According to reports, health officials are concerned that undocumented immigrants are avoiding medical treatment to limit their paper (or electronic) trail, especially if that medical trail can be traced by authorities. But lack of clinical care can be just as costly if communicable diseases go untreated.

Putting politics aside, two industry experts helped ADVANCE untangle the major documentation and health issues this investigation brings to light.

The Dangers of Medical Identity Theft
Chrisann Lemery, MS, RHIA, HIPAA security officer and assistant privacy officer for WEA Trust Insurance and co-author of Medical Identity Theft, said when a person uses another's identity to access medical care, it compromises patient outcome. Medical information about the identity "thief" becomes a part of the "victim's" record, and treatment decisions may be based on inaccurate information. For example, if a thief has a reaction to drugs, the victim may be denied that drug in a future emergency. "Depending on what the thief's history is, it could be detrimental to the person's treatment," Lemery said. "It could even result in death."

In the North Carolina case, the victim was deceased, so the inaccurate information didn't affect his or her treatment. But health risks go the other way too, Lemery said; the alleged thief may have received improper treatment resulting from the victim's medical history.

Medical identity theft is a rising problem, and one that carries no easy solution. Photo identification can verify a patient's identity, Lemery said, but it still leaves loopholes. "If you think of how many people have a driver's license, it's a start," she said. "But what do you do if somebody doesn't have a photo ID?"

Hospitals have an obligation to provide care, and demanding identification before proceeding with treatment could hinder patient outcomes. Ultimately, Lemery said, facilities must keep the patient's health in mind.

Protecting Patient Privacy
Pam Dixon, executive director of the World Privacy Forum, noted that health care providers can benefit from knowing a patient's past conditions, but she is leery about denying the right to anonymity. "I'm concerned that we will really no longer have anonymous health care in this country," she said. "I think it's going to become increasingly difficult to be a John or Jane Doe getting health care."

There are times when people who have insurance choose to pay for services in cash so they can remain anonymous, especially when treating a delicate or embarrassing medical situation, Dixon explained. Mandating photo identification would eliminate that possibility.

Identification requirements can prevent insurance fraud, a concern for payers and providers alike, but they also infringe upon a patient's right to privacy. Security is important, Dixon said, but it's unclear how stringent ID requirements would fare in a medical setting. "Are we going to have a TSA-style identity check in emergency rooms? Is that what we're building up to?" she asked.

In the North Carolina case, another privacy issue was raised regarding how immigration authorities learned about the woman's medical records. According to Dixon, HIPAA includes several exemptions for law enforcement, but investigations usually involve oversight. That didn't seem to be the case in North Carolina. "There are some real questions about privacy and confidentiality in this context," Dixon asserted.

While she explained that criminal behavior like medical identity theft is a "game-changer," Dixon said the woman was ultimately denied her right to medical privacy when her records became part of the investigation.

Concerns over privacy rights will become even more complex in the coming years, Dixon predicted, especially as EHR and health information exchange become more prevalent. As HIT expands, patients must decide if they're willing to sacrifice privacy for greater security.

"One of the questions we have to ask is: do we want immigration officials pawing through medical records to find criminals or people they believe are criminals?" Dixon said.

Public Health Concerns
What most troubles health officials, however, is when the use of medical records in investigations deters people from seeking much-needed treatment.

"Of course we don't want people running around using fake Social Security numbers or dead people's Social Security numbers--that's just dangerous. But on the other hand, do we want to chill access to health care?" Dixon questioned.

While anyone can be susceptible to disease, undocumented immigrants often live in close quarters and move frequently--a lifestyle that lends to increased risk of disease spread. Tuberculosis came to Dixon's mind as a disease that can be easily transferred from person-to-person and, if left untreated, can not only jeopardize health among other immigrants, but the entire population as well.

Lemery agreed that turning off immigrants to medical care could lead to a public health problem, but she also noted that no one can force people to get treated. Whether a U.S. citizen or not, everyone has the right to seek or reject medical care.

While America's response to illegal immigration will be multi-faceted, Dixon cited a potential solution to health concerns. In California, a program called MiVia lets migrant workers and family members track their health through electronic personal health records. Launched in 2003, MiVia encourages immigrants to seek care at any of several clinics throughout the state, and doctors can log in to the EHR to provide quality care.

Health care can travel with the workers, Dixon said, but more importantly, it doesn't criminalize them for seeking care.

Collins, Kristin. "Are medical records used to deport migrants?" McClatchy Newspapers. Aug. 2, 2008. Available online at
 "Illegal aliens may fear to seek care." The News and Observer. Aug. 18, 2008. Available online at

Cheryl McEvoy is an editorial assistant with ADVANCE.

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