August 30, 2012

Question:

Our community has a large physician group that has its own internal quality review process.  The group is not affiliated with our hospital, but the members of the group have clinical privileges here.  Recently, the group’s president proposed that the hospital and the group notify each other if certain events occur (for example, if concerns are raised at the hospital about a group physician).  The group president suggested this would allow both the hospital and group to do a better job assessing the qualifications of physicians.  This seems to make sense, but is such sharing of information permitted?

Answer:

First, check your state peer review statute.  It may expressly permit (or prohibit) the sharing of peer review information in the situation described.

If state law does not specifically address the sharing of information, consider whether the group is nonetheless covered by the peer review statute.  If the group meets the statute’s definition of a “peer review entity” that is governed by the statute, then you would have peer review information being shared between two entities covered by the statute.  This should reduce any risk of sharing information.

Even if the group meets the definition of a “peer review entity” under state law, we would still recommend that hospitals and groups enter into “Information Sharing Agreements” before sharing peer review information.  Such agreements make clear that the purpose of the disclosure is to promote patient safety, which is the same general purpose advanced by peer review protection laws.  This reduces the risk that the appropriate sharing of information will be viewed as a “waiver” of the peer review privilege.  An Information Sharing Agreement also describes exactly what type of peer review information may be shared, and whether such sharing will only occur upon request or proactively, when a certain event occurs.

An Information Sharing Agreement should require that physicians consent to the sharing of information.  This eliminates the risk that the physician whose information is shared will claim that either the hospital or a group was trying to harm the physician economically.

If state law is silent about the sharing of information and the physician group is not included in the definition of a “peer review entity,” it may still be possible to share peer review information.  However, in that case, an Information Sharing Agreement is even more important.

For a more in-depth discussion of sharing peer review information, join us in Scottsdale October 4-6, 2012 for The Peer Review Clinic.