A. Background
Wolfsohn is a physician specializing in pain management. He has been licensed by the Medical Board to practice medicine since 1977.
In December 2014, the Medical Board received a report from a law enforcement officer that Wolfsohn may be overprescribing controlled substances to patients. The Medical Board opened an investigation and obtained from the Controlled Substance Utilization Review and Evaluation System
Dr. Shoaib Naqvi is a medical consultant for the DCA with the "responsibility to maintain familiarity with the standard of medical practice in the State of California." Naqvi reviewed the CURES report and identified five patients (J.A., R.G., V.J., J.R. and V.H.; collectively, the patients) to whom, in Naqvi's opinion, Wolfsohn "prescribed controlled substances in a manner that appeared to be inconsistent with the standard of care for prescribing those drugs." According to Naqvi, the "only way to determine whether Wolfsohn properly and safely administered any of these controlled substances to the five patients ... is to obtain and review the complete and accurate medical records of the five patients."
In early September 2016, the DCA issued and served on Wolfsohn an investigational subpoena duces tecum pursuant to Government Code section 11181. The subpoena commanded Wolfsohn to produce "the complete medical record" for each of the patients for the period January 1, 2014 through March 31, 2016. The document production was set to take place before DCA investigator Tracy Tu on September 26, 2016. It does not appear from our record that the DCA provided a copy of the subpoena to the patients or otherwise notified them that it was seeking their medical records from Wolfsohn prior to the stated production date.
On September 20, 2016, Wolfsohn's attorney delivered a letter to Tu stating, "[W]e contacted the patients," who "confirmed that they do not want [Tu] or the Medical Board to have access to their confidential medical information." Accordingly, Wolfsohn would "refuse to comply with the subpoena duces tecum and assert [the patients'] constitutional privacy rights
Wolfsohn did not appear or produce the requested medical records pursuant to the subpoena.
About five months later, on February 23, 2017, Medical Board investigator Tu sent by regular and certified mail a letter to the patients stating that the DCA's division of investigation "is attempting to obtain your medical records from Marc Wolfsohn, M.D. via service of a subpoena" (capitalization omitted) that "was served on 09/09/16 compelling the production of your records by 09/26/16. [¶] If you have an objection to the use of your records in this process, you may wish to consult an attorney to discuss your options."
Enclosed with the letter is a copy of the subpoena served on Wolfsohn and a document titled "Notice to Medical Consumers." (Capitalization omitted.) This document describes the investigatory role of the DCA's division of investigation, and states that DCA "[i]nvestigators and medical consultants read and evaluate the medical records of patients who were treated by those whose practices have come under question." Although "patient records are kept confidential ... during the investigation," the "records may become part of the official proceeding record. ... [¶] If you have an objection to the use of your records in this process, you may wish to consult an attorney to discuss your options."
B. DCA's Petition to Compel Compliance with Subpoena
On October 30, 2017, the Attorney General, on behalf of the DCA, filed a petition in Los Angeles County Superior Court for an order compelling Wolfsohn to comply with the subpoena. The petition names Wolfsohn as the sole respondent and names Kimberly Kirchmeyer, in her capacity as the executive director of the Medical Board, as the real party in interest.
The petition was supported by Naqvi's declaration. Naqvi described generally the various statutory classes, or schedules, of controlled substances (see Health & Saf. Code, §§ 11054 - 11058 ); referred to a measurement known as "morphine equivalent dosing" (MED), which is used to compare different
Naqvi also opined as to actions physicians must take to comply with the standard of care when prescribing controlled substances. These include conducting an appropriate examination of the patient, documenting the diagnosis underlying the prescription, obtaining informed consent regarding potential risks (which Naqvi stated is required when the MED value exceeds 100), and evaluating "any co-morbid conditions that could be worsened by the use of [the] drug."
According to Naqvi, the CURES report for Wolfsohn revealed that each of the patients whose records are sought in the subpoena, had "prescription patterns that, in the absence of any other information, appear to represent concerning departures from the standard of care for prescribing these controlled substances." He described the drugs that (according to the CURES report) Wolfsohn prescribed to each patient, the amount of each prescribed drug, and the frequency of the prescriptions fulfilled. Based on this data, he estimated a range of MED values for the patients ranging from 80 to 300.
Naqvi does not opine that the data or the MED level indicated by the CURES report constitutes a violation of the Medical Practices Act or breaches a standard of care. Rather, as to each patient, he states: A "review of [the] patient['s] medical record is necessary to confirm that an appropriate examination or screening was done before ... Wolfsohn prescribed this medication regimen, and also to determine whether regular assessments of the efficacy and effects of the treatment regimen were not only conducted but documented, and that the appropriate monitoring measures were performed. If ... Wolfsohn failed to properly screen and subsequently monitor [the patient] while prescribing these medications, his care may be found to fall below the standard of care, violate the Medical Practice Act and place his patients at undue risk."
On November 2, 2017, the DCA served Wolfsohn's counsel with notice of a hearing on the petition for December 5, 2017. The DCA did not serve the notice or the petition on any of the patients.
On December 5, 2017, at the hearing on the DCA's petition, the court issued an order to Wolfsohn to show cause why he "has not attended and testified or produced the records as requested by [DCA]." The court set a hearing on the order to show cause for December 13. The court also ordered the DCA to give notice of the hearing to the patients, but did not specify the manner of notice or a deadline for doing so.
On December 12, 2017, Wolfsohn filed objections to the DCA's evidence and an opposition to the petition. He also filed a declaration by Dr. Standiford Helm, a physician specializing in pain management.
On the same day, counsel for the patients filed a "notice of special appearance" (capitalization omitted), stating that they "object to these proceedings on the ground that this [c]ourt lacks jurisdiction over these patients and this [c]ourt is now proceeding without according adequate due process of law. These patients hereby further object based on their constitutional right to privacy, the Pain Patient Bill of Rights, equal protection of law, the doctor-patient privilege, and the psychotherapist-patient privilege."
At the December 13 hearing, counsel for the patients reiterated their objections and requested "more time to review the papers and to have an
Wolfsohn timely appealed.
DISCUSSION
Wolfsohn contends: (1) The court did not have jurisdiction to enforce the subpoena because the patients were not parties to the proceeding; (2) The DCA failed to provide the patients with proper or adequate notice of the subpoena; (3) By seeking the patients' "complete medical records," the subpoena was drawn too broadly; (4) The court erred by refusing to permit him to take the deposition of Naqvi; and (5) The subpoena was not supported by competent evidence of good cause. We address the good cause issue first and, because our conclusion is dispositive, do not reach the remaining issues.
A. Medical Board Investigations and Subpoena Power
The Medical Board, a unit of the DCA, is "charged with the duty to protect the public against incompetent, impaired, or negligent physicians." ( Arnett v. Dal Cielo (1996)
If a subpoenaed person does not comply with a subpoena, the DCA may petition
Upon the filing of a petition under Government Code section 11187, the court shall issue an order directing the subpoenaed person to show cause why he or she has not complied with the subpoena. ( Gov. Code, § 11188.) At the hearing on the order to show cause, the court shall determine the validity of any objections to the subpoena. (
B. The Patients' Privacy Rights
The California Constitution guarantees to individuals the right of "privacy." ( Cal. Const., art. I, § 1 ; Lewis , supra ,
The DCA does not dispute that Wolfsohn's patients have a right to privacy with respect to information contained in the requested medical records. Indeed, that right is well-settled. (See Hill , supra ,
The right to privacy, however, is not absolute. ( Hill , supra ,
Medical patients' privacy interest, our Supreme Court has observed, derives from their expectation of privacy in their physician's files, which "may include descriptions of symptoms, family history, diagnoses, test results, and other intimate details concerning treatment." ( Lewis , supra ,
Courts have applied the Hill framework to cases involving the Medical Board's access to a patient's medical records by allowing the Medical Board to review such records when it establishes "good cause" for the examination. (See, e.g., Grafilo v. Cohanshohet (2019)
We review the court's conclusion that the DCA established good cause to support the subpoena under the substantial evidence standard. ( Fett , supra ,
In Cohanshohet , supra ,
The Cohanshohet court concluded that the Medical Board failed to demonstrate good cause. ( Cohanshohet , supra ,
The Cohanshohet court, we believe, appropriately balanced the competing privacy and state interests concerning access to patient medical records by requiring that the Medical Board make a sufficient evidentiary showing that the subpoenaed physician has been issuing prescriptions in violation of law or the particular applicable standard of care. In Cohanshohet , the evidence was insufficient because Naqvi's declaration lacked information regarding the number of patients the physician treated during the relevant period, how other similarly-situated physicians might lawfully prescribe the drugs in question, and the likelihood that the suspect prescriptions could have been properly issued.
Cohanshohet does not suggest, nor do we, that the evidence absent in that case, or ours, must be present in other cases, or that courts should not consider the presence or absence of other facts bearing upon the patients' privacy interests, the state's interest, and protective measures and alternatives. In Cross , supra ,
The DCA argues that the instant case is distinguishable from Cohanshohet because "the prescribing dosages of opiates in this case are much higher than those examined in Cohanshohet. " Even if we assume that Naqvi's statements regarding Wolfsohn's prescriptions are admissible, the statements regarding the dosages do not cure the defects we have identified.
The DCA also asserts that the physician in Cohanshohet "claimed to practice end-of-life medicine" that may have justified the prescriptions. The fact that Wolfsohn did not state that he deals with end-of-life patients is immaterial. Wolfsohn is a pain management specialist who treats "patients with severe pain or chronic intractable pain." He defined intractable pain as pain that "will not go away" and about which "conservative measures" of treatment have failed. As with Dr. Cohanshohet, "it is reasonable to assume at least some of his patients would require treatment for pain that would exceed the recommended dose." ( Cohanshohet , supra ,
The DCA also asserts that the Cohanshohet court "found it significant to its good cause evaluation that the triggering complaint leading to the investigation was anonymous." Even if we agreed that the Cohanshohet court considered that fact significant, it is not a basis for a different result in this case. Here, investigator Tu stated that the DCA began its investigation after receiving "a complaint" from a named officer with the "Ventura County Interagency Pharmaceutical Crimes Unit." No information was provided regarding the nature of the complaint or the basis upon which the officer made the complaint. Thus, although the complainant is not anonymous, his identification adds nothing to the good cause determination.
Accordingly, we reverse the court's order.
The court's December 13, 2017 order granting the DCA's petition to compel Wolfsohn to comply with its subpoena is reversed.
Wolfsohn is awarded his costs on appeal.
We concur.
JOHNSON, J.
WEINGART, J.
Notes
Judge of the Los Angeles Superior Court, assigned by the Chief Justice pursuant to article VI, section 6 of the California Constitution.
CURES is a prescription drug monitoring program that includes information regarding prescriptions for certain controlled substances. (Health & Saf. Code, § 11165, subds. (a) & (d) ; Lewis v. Superior Court (2017)
The DCA did not offer the CURES report in support of its petition and it is not included in our record.
The DCA objected to Wolfsohn's opposition papers on the ground they were untimely. The court overruled the objection and considered the opposition papers.
The Pain Patient Bill of Rights provides that a "patient who suffers from severe chronic intractable pain has the option to request or reject the use of any or all modalities in order to relieve his or her pain." (Health & Saf. Code, § 124961, subd. (a).)
Under Government Code section 11181, the subpoena power is held by "the department head." That person "may delegate the powers conferred upon him [or her] ... to any officer of the department he [or she] authorizes to conduct the investigation." (Gov. Code, § 11182.) Wolfsohn does not dispute that the person issuing the subpoena in this case had the authority to issue the subpoena.
In Hill , our Supreme Court distinguished informational privacy from "autonomy privacy": "interests in making intimate personal decisions or conducting personal activities without observation, intrusion, or interference." (Hill , supra ,
Cohanshohet was decided after the parties filed their briefs in this case. We requested the parties submit supplemental briefs addressing the application of Cohanshohet to the issues in this case. We have received and considered the briefs.
We express no view on the merits of Wolfsohn's remaining arguments. Our conclusion does not preclude the DCA from issuing or enforcing subpoenas that are supported by good cause and otherwise lawful.
