The deeply personal, private medical records of at least eight different women were found littering two blocks near an Upper East Side OB-GYN’s office, out of step with the requirements under the law. Partial pap smear results, lab tests, sonograms, surgical pathology reports, insurance cards and birth control prescription information were among what was found covering the street and sidewalk, revealing birth dates, spouse and relatives names, maiden names, addresses, phone numbers, Social Security numbers, sexual transmitted infection status and even genetic abnormalities.
A reader contacted Upper East Site last Wednesday, March 22nd, after discovering the sidewalk and roadway near the intersection of East 65th Street and Lexington Avenue peppered with poorly destroyed medical records, which had only been torn in half or into thirds, and not shredded to protect patient privacy.
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After arriving at the intersection, Upper East Site spent more than a half hour retrieving 110 pieces of torn paper from the street, sidewalk and puddles on Lexington Avenue between East 64th and 65th Streets, as well as on East 65th Street just west of Lexington Avenue to Third Avenue.
Upon further review, Upper East Site found that the records appear to come from more than 100 different documents spanning the course of 21 years.
Only a handful of the strips of paper come from the same medical documents, which were originally generated by at least 16 different genetic testing services, testing laboratories, hospitals, insurance companies and imaging centers, including New York-Presbyterian, Mount Sinai, Quest Diagnostics, Walgreens, East River Medical Imaging, Counsyl, Aetna and Oxford Health.
Records retrieved by Upper East Site show that one patient, a woman who will celebrate her 36th birthday in May, is listed as positive for being a carrier of the gene that causes cystic fibrosis, a life-threatening inherited genetic disease that damages the lungs and other organs.
Additional documents reveal laboratory tests on the same woman, done in consecutive years, show she is DNA-positive for the human papillomavirus, or HPV — the virus that causes genital warts and is linked to cervical cancer — and listed as ‘high risk,’ with the words underlined by hand in all three documents.
That same woman tested negative for the gene that causes Fragile X Syndrome, the genetic disorder that causes developmental and learning delays, as well as social and behavioral problems. The name and birthday of her husband is also included in the discarded records.
The private medical documents also reveal the name, address, date of birth and telephone number of a married 37-year-old Upper East Sider with Oxford Health insurance, as well as her husband, who is almost exactly six months younger than her.
The second woman is HPV negative and was scheduled to have her cervix dilated the day prior to her expected due date, according to a ‘Universal Booking Sheet for Labor and Delivery’ from New York-Presbyterian Hospital. She was also prescribed Loestrin tablets for birth control at one point, which were sent to a Walgreens pharmacy to be filled.
A now 66-year-old Brooklyn woman’s medical records were also among the bunch, which reveal her name, address and date of birth, as well as results from a surgical pathology report which included a diagnosis — as well as a pathology report from Mount Sinai for tissue from the woman’s left breast.
The name, maiden name, address, phone number, full Social Security number, religion and health insurance information of a 39-year-old Jewish woman who lives on the 10th floor of a high-rise luxury building in Midtown was also among the records retrieved by Upper East Site.
The woman also had an osteoporosis study done on her lumbar spine from L2 through L4, according to the documents, and is married to a man two years and 10 months older than her. She has a 646 phone number, his has a 917 area code.
An old obstetrics report from a now 50-year-old woman, as well as her pap smear pathology report, were found among the records, as well as a document listing four of her relatives.
Documents also included partial names and birth dates for two other women, a 39-year-old and a 63-year-old whose report indicated she was afflicted with ‘tiny cysts.’
A genetic report identified one woman as being 99% Ashkenazi Jew, while another document indicates endometrium curettage, a procedure in which the cervical canal and uterine lining are scraped to remove abnormal tissue, was performed.
Three sets of sonograms were also found among the private medical documents left to litter the streets of Lenox Hill.
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Many of the records, which date back as far as 1993 and as late as 2014, include the name of Dr. Martin Gubernick, a New York-Presbyterian Hospital-affiliated OB-GYN, and voluntary faculty member at Weill-Cornell Medical Center, whose office is located at 131 East 65th Street, near the corner of Lexington Avenue, on the Upper East Side — exactly the same location where the discarded documents were discovered.
In fact, a number of the records retrieved were picked up from directly in front of the Dr. Gubernick’s office.
Under the Health Insurance Portability and Accountability Act, better known as HIPAA, health care providers and insurance companies nationwide are required to safeguard the private protected health information of patients and dispose of them properly.
Complaints can be filed online with the US Department of Health and Human Services Office for Civil Rights, which is tasked with enforcing HIPAA’s medical information privacy rules, and if found in violation of the law, the penalties are costly.
Last year, a Massachusetts dermatology center paid a $300,640 settlement to HHS and agreed to two years of monitoring after empty specimen containers with protected health information on the labels, including patient names and dates of birth, were thrown away in the dumpster in their parking lot.
“Covered entities must implement reasonable safeguards to limit incidental, and avoid prohibited, uses and disclosures of [protected health information], including in connection with the disposal of such information,” a spokesperson for US Department of Health and Human Services told Upper East Site in response to an inquiry.
“Failing to implement reasonable safeguards to protect PHI in connection with disposal could result in impermissible disclosures … and potential violations of the HIPAA Rules.”
Speaking candidly with Upper East Site, Dr. Gubernick explained how a ‘perfect storm’ of events unfolded in his office over the past few weeks that lead to the documents being accidentally discarded like regular trash.
Dr. Gurbernick showed us how his entire record keeping system is digital and most records handled by his office are electronic, however, he explained that there are old records waiting to be shredded by his staff in the basement of the practice, held in a storage space behind two locked doors to which only his staff had access. Upper East Site saw, but was not allowed to photograph the space.
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Several weeks ago, there was a flood inside the Upper East Side obstetrician’s practice that would require a complete replacement of the flooring, the doctor told us. Rather than shut down his practice for two weeks need to finish the job, the longtime UES physician had contractors do the work overnight so that he could continue to see expecting mothers, he said.
Dr. Gubernick showed Upper East Site photos of the work being done inside the medical office, as well as invoices from contractors he hired to replace the floor, which appeared to be brand new during our visit.
One of the workers hired by the contractors apparently grabbed one of the bags medical records meant to be destroyed after requiring access to the space for another reason, packed them up with their construction waste and put it out on the curb last Tuesday night to be picked up by a private carting service, Dr. Gubernick said.
Pointing to a glaring problem faced by many Upper East Side businesses and residential buildings, the doctor believes a panhandler or homeless person dug through his bags looking for anything of value and dumped the documents on the ground — where we know they would ultimately be dragged down the street by traffic.
Gubernick clearly recognizes the seriousness the loss of these medical documents posed and how the incident could impact confidence in the well-respected physician in the final stages of his medical career, but he also pointed the confluence of unforeseen circumstances that could have happened to any doctor already taking the proper steps to protect patient privacy.
The doctor tells Upper East Site that if he could do anything different, he would shut down his office for the two weeks so that construction could have been done during the day, when a better eye could be kept on the workers on site — even if that meant putting an added burden on his patients.
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Despite serval attempts to contact the women whose personal and private medical records were found on the street, none could be reached by time of publication.
Upper East Site was able to contact one patient’s husband, whose name and phone number were listed on a form filled out by his wife.
The man, who confirmed his wife was a patient of Dr. Gubernick and was understandably surprised to learn what we had uncovered, did not respond to any further communications following a brief phone call on Monday.
The medical records retrieved by Upper East Site have since been returned to Dr. Gubernick, who has assured us they will be properly destroyed this time.
