Webinar presenters Dyanne Greer and Roger Blevins answered a number of your questions after their presentation, "Understanding Medical Records for Your Child Abuse Investigation and Prosecution Efforts." Here are a few of their responses.
Audience Question: Are there state directories of child abuse PAs and child abuse pediatricians, etc. readily available like on the Web center?
Roger Blevins: Unfortunately, there aren't. In England, there are. Unfortunately, there are not in the United States. You should have, most states have a children's hospital and that's where you should find a child abuse pediatrician in a children hospital. Sometimes we have people in the community, general pediatricians, who do child abuse for that area and those folks are important to talk to as well.
Audience Question: Roger, continuing with you. You mentioned a name of subscription service that summarizes child abuse investigation literature. Could you restate the name of that service and how we find it?
Roger Blevins: Yeah, actually it's not investigation literature. It's child abuse related medical literature. The Massachusetts quarterly …
Dyanne Greer: It's called The Child Abuse Quarterly. It's about a 120 bucks a year. Chris, I can give you that information. I don't have it with me but I can certainly have it you. Our office is subscribed to it. It's very useful. They break it down. They review literature and everything from sex abuse, morbidity and mortality, to autopsies to social science, etc. It's a phenomenal resource. It does come out quarterly — amazing — that's the name of it. It reviews this lit and it's readable. It summarizes the most recent lit and it can be big resource. Chris, I'll make sure to get that info to you.
Audience Question: As soon as Dyanne gets me that info, we’ll be sure to put that in the course page for this webinar. When the webinar is posted back to the website, just revisit and we'll have that link available for you. Thanks. Roger, can you explain SNAT again?
Roger Blevins: Yeah, some people refer to it as SNAT. It's actually a skeletal survey. Sometimes people — suspected non-accidental trauma — bone survey. It's actually referred to as a skeletal survey. It is not a bone scan. A bone scan is what we do when we inject some radiologic substance into the child. These are just plain x-rays, several views each.
Audience Question: Next question/comment. One audience member sent, "I'm a registered nurse investigator with adult protective services in Arizona. I have found that if an autopsy report says natural causes for the cause of death does not mean maltreatment and did not occur especially in a client with this disease processes. Many investigators will stop the process when they see natural causes on the death certification." Any thoughts?
Dyanne Greer: Yeah, I agree with that. It's not for adults, but for children as well. A lot of times, they'll come up either as undetermined or they'll attribute to — we have a case now that attributes death to an infection, and the reason it killed the child was because he was not treated. That's being prosecuted. We as prosecutors, not because it does not come across as a homicide, as listed as either natural or accidental, does not stop us from prosecuting and should not stop an investigator from continuing the investigation. A lot of times the Medical Examiner does not have all of the information you and law enforcement have at that point. Sometimes we need to go back to the Medical Examiner, which is what we did in this particular case and say this is now what we now know. They didn't change their view because in their view the child did die of an infection. We are prosecuting that case as a child abuse because of what we in the background knew. Don't stop there. That's an excellent question and I'm glad that person brought that up.
Audience Question: When you're looking at a child abuse case, what is the role of school records or teacher impression or school nurse notes?
Dyanne Greer: Absolutely critical. Particularly when you got a child who is going to school and you got some issues, I always encourage the investigators to go back with a school-age child and find out whether or not if the school is noticing things as well. A lot of times the school will note things, how the child is acting or if there are unexplained bruises that may or may not rise to the level of report because the child explains it away. The school may not be aware of everything that's going on. I think it is very important to include school records and pre-school records on children when you are going to put this picture together.
Audience Question: What is the role of the Federal Educational Right to Privacy Act (FERPA) as well? How does that been folding into this conversation?
Dyanne Greer: It shouldn't be a problem due to the fact that this is a child abuse investigation. I can't really speak to the educational privacy act. That's not something I'm totally familiar with. I'm going to leave that to someone else. Try to find somebody in your state that can talk to you about how the educational privacy act relates when it is a child abuse investigation. I'm just not as familiar with that to be able to comment on that particularly.
Audience Question: Are schools reports and notes protected by HIPAA? I'm assuming this is related to the health records the nurse at the school gathers. Are those protected by HIPAA?
Dyanne Greer: HIPAA covers agencies that are considered "covered entities" to include health plans, Health Care Clearinghouse, and health care providers. They may but again HIPAA has an exception for child abuse. There’s this specific exception for child abuse. They should be easily obtained through child abuse. You may need to go to possibly as prosecutors go to your civil division, if you have one, and find out what, we work closely with our civil division when we need those kinds of records to see if we have issues. They are more familiar to things like the Educational Privacy Act than we as prosecutors are. Generally, if it's child abuse related question, I will tell you that HIPAA says you can get the record. One of the drawbacks we have found is that HIPAA does not explicitly state that doctors can talk to you about those records. A lot of times we need to get a court order to say you are hereby allowed and ordered to talk to the prosecutors and law enforcement about this. We have a statute, DCS, Department of Child Safety, can't talk to us without a court order either. That's easy enough to get. Be aware of the fact that maybe it's something you have to do. If you have a doctor who says I can’t talk to you because HIPAA tells me I can give you the records but it doesn’t tell me I can talk to you and I’m worried about getting sued, we will then get a court order to allow that.
Audience Question: This actually brings me to the next question that we had come in. This is going back to your conversation about hospital personnel — if not all records people know that HIPAA does not apply to certain types of investigation, how can prosecutors or law enforcement work with hospitals ahead of time to make things easier during an investigation? This kind of reminds me of an old saying that one of our speakers always say, you don't make friends at 2 a.m, meaning that the time to make this or create great working relationships is not when you're in the middle of the crisis. It's ahead of time. Dyanne, how have you guys reached out and worked with these organizations so that you aren't trying to make friends at 2 am so to speak?
Dyanne Greer: I have called and met up, I contact the legal division. You do that. Most hospitals nowadays are part of an organization. For example, we have Mercy Care. Once you identify the hospital and their parent organizations, as a prosecutor, I would highly recommend you be the one to, lawyer-to-lawyer, it is important where you set it up and say that this is what we want to do. I have met with medical records people for the same reason. That's something that I think proactively prosecuting agency should do with hospitals in your jurisdictions, say what can we do, what do you need make sure the request we're giving you is HIPAA – compliant so that you can say yes it's okay. How you do you want us to handle this? You set up those interactions early. You set up a system. You at least have to have a system set up. If you have a glitch you know where you have to go to hopefully get the problem resolved.
Audience Question: There's a great comment here from Jill. As a coroner, I'm unable to get any school records in Colorado due to federal rulings. Dyanne, you might have insights on this or is this a local statute?. How does this work?
Dyanne Greer: I think again, I think that's the Educational Privacy Act which I'm not familiar with. However, if it's a child abuse investigation, there may be again, going to the EPA, maybe this is something we need to look at and try to add in because there's a glitch in my knowledge base that I certainly want to solve so that we don't have decisions. That's a good point. We do have to take a look at the EPA and figure out does it provide for child abuse and find out what the issues are.
Audience Question/Comment: Please don't forget. There are board certified medical legal death investigators who are also critically involved and are medically trained. That's a great sharing there. Thank you, Jill.
Dyanne Greer: Absolutely true They are very important to us as well.
Audience Question: You talk about going out and actually talking to doctors or nurses or EMF providers in getting their impressions that aren't necessarily reflected in the "check the box forms." These individuals are really busy. They might deal with a lot of patients in any given day. How do you trust a health professional's recollections of such if they're working in such a very busy setting?
Dyanne Greer: Couple of things. One, care and feeding of your medical witnesses is very important for law enforcement and prosecutors. One of the things is never to show up in the hospital and ask to see somebody. That will never work. They might be in the middle of rounds or they're seeing patients or whatever. You don't want to do that. Finding out where their office is, making contact with their secretary and knowing their names is critical. You call back that person. You develop a relationship with them. Okay, I need to see so and so about this patient. I have obtained medical records. I would like to send them in advance the issues that we are going to talk to them about. I would pull out all the records that pertain to the person I'm talking to so that in advance they don't have to go the hospital records and pull them out and go through the entire file. I have pulled it out and I have provided it to them in advance so that when I go to meet them for a regularly scheduled meeting, they have the information to do it. When I talk about legal issues, I always have law enforcement with me. I never want myself to be a witness. I will drag in my investigator say let's go talk to this doctor. My office will be generally the one because I have the medical records. I organize them. I know what I'm going to ask them about. I provide it to their staff so they can have it in advance and I work around their schedule.
Roger Blevins: Yeah and a lot of medical providers, nurse practitioners, and PAs are scared to death of the witness stand. They are not comfy testifying, that kind of environment is kind of anathema to most medical providers except for those in child abuse pediatrics. You have to give them a little understanding. Try to make sure that you take out little time as possible. They're getting paid by piecework now. They're no longer a healthcare provider there but as resource-based relative value unit. It's important to take as little time as you can and to make it as convenient for them. As opposed to have them come to your office, go to theirs. If you could do it over lunch, do it over lunch. If you can do it after hours, do it after hours. Anything you can do to make their lives a little bit easier will probably get you a lot more cooperation.
Dyanne Greer: It's also a matter of if it's going to trial, giving them time to prep them for the witness stand. Say what you think the defense is going to be at that point, what kind of things they are going to be challenged on. Give them some kind of guidelines and guidance to how to respond on the stand. Roger said a lot of them are scared and we can hopefully make it a little less traumatic by telling them that these are the points I want to go over with you and also asking them, have I missed anything? What kind of things do you want me to ask you to get your point across? So it's a matter of them teaching you, and you teaching them at the same time.
Audience Question: Who tends to make the most impactful witnesses? Nurses? Doctors? PAs? Who are the best witnesses?
Dyanne Greer: There's a dispute about that. Most people would say the doctor anytime, but I can tell you if you present it to your jury and you prep, for example, I have Roger in many cases. When I go through his resumè in terms of his knowledge base and compare that to an ER doc who has seen maybe 3 child abuse kids in the last 5 years. Even though it's a doctor versus a PA, juries will listen. A lot of it has to do with the jurors' impression, initially, that a doctor is obviously going to be better. That is not true. We have the same issue with sex assault nurse examiners versus emergency room people. It's how you present it to your jury in terms of qualifications and knowledge base.
Roger Blevins: Yeah and you have somebody who can communicate with lay people well — not everybody could do that. It's not necessarily a sentiment of your profession. I do a thing where this is so simple a caveman could understand it. When I get up to the witness stand, I simplify everything as well as I actually can so the jury can understand what I'm saying. I'm not really whetted to a lot of jargon.
Dyanne Greer: Doctors specifically non-child abuse, non-pediatric specialist have a hard time dumbing it down for the jury.
Audience Question: Does the process change if a health care worker is the one who had initially called law enforcement about the suspected child abuse?
Dyanne Greer: No, it's just a matter of depending on – we have a lot of that because the hospital will see a child, okay this kid's a code, we're calling law enforcement. It's still the same process, law enforcement will go in. You still need to talk about the same people, get the same information. The fact that it coming from the hospital won't change anything. You would probably get little more information because the people who is calling it in saying this is why I think this is abuse. Whether or not that's documented in their note …it may or may not be. Still you have to develop the same information whether the school has called it in and you are bringing the child to a hospital or the hospital itself is calling law enforcement because they were the ones that see the child first.
Audience Question: If the parent does not provide primary physician information, is it possible to contact nearby medical groups and ask them if the child is a patient?
Dyanne Greer: What I would do in those cases is I would take a look at the hospital admissions. If you have a hospital admission, you take a look at insurance. You might have to get a subpoena or court order for the insurance information. They will tell you every place they have paid out medical bills for.
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