Board of Registration in Medicine v. Hallmark Health Corp.

26 Mass. L. Rptr. 394
CourtMassachusetts Superior Court
DecidedDecember 22, 2009
DocketNo. 20071077C
StatusPublished

This text of 26 Mass. L. Rptr. 394 (Board of Registration in Medicine v. Hallmark Health Corp.) is published on Counsel Stack Legal Research, covering Massachusetts Superior Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Board of Registration in Medicine v. Hallmark Health Corp., 26 Mass. L. Rptr. 394 (Mass. Ct. App. 2009).

Opinion

Lauriat, Peter M., J.

INTRODUCTION

The Board of Registration in Medicine (the “Board”) brought this action against the defendants, Hallmark Health Corporation, Lawrence Memorial Hospital, Melrose-Wakefield Hospital, (collectively, “Hallmark”) and Winchester Hospital, seeking access to materials located in a medical doctor’s credentialing files from the hospitals in connection with the Board’s investigation of the doctor, Dr. John Doe (“Dr. Doe”), prior to the commencement of an adjudicatory proceeding pursuant to G.L.c. 30A.1 A Superior Court judge awarded summary judgment to Hallmark, and the Board appealed. The Supreme Judicial Court vacated the summary judgment decision and required the court to conduct an individualized review of each document which Hallmark claims is privileged. For the following reasons, Hallmark is ordered to produce to the Board the documents identified in this Memorandum of Decision within fifteen days of the date of the Order set forth below.

BACKGROUND

This case stems from an investigation initiated by the disciplinary unit of the Board in response to a patient complaint and subsequent information which suggested that Dr. Doe had fraudulently obtained a renewal of his medical license by failing to report criminal charges on his medical license renewal applications. Board of Registration in Med. v. Hallmark Health Corp., 454 Mass. 498, 500 (2009). The Board also determined that an investigation was required as to whether Dr. Doe practiced medicine while impaired by alcohol or drugs. Id. On Februaiy 13, 2007, the Board issued subpoenas to the defendant hospitals seeking documents related to Dr. Doe’s credentialing, employment, and competence to practice medicine. Id. The Board also sought incident reports and complaints related to Dr. Doe. The defendant hospitals refused to produce these documents and asserted that they are protected under the medical peer review privilege.

Pursuant to Hallmark’s medical staff credentialing policy, physicians seeking clinical privileges at Hallmark are required to apply for an initial appointment and must apply for reappointment at periodic intervals of not greater than two years. Board of Registration in [395]*395Med. v. Hallmark Health Corp., 454 Mass. at 502. Physicians seeking an initial appointment must provide information such as prior education, training, experience, and licensure. Id. Physicians are also required to disclose potentially harmful information such as whether the applicant has ever been a criminal defendant, lost a professional license, had clinical privileges withdrawn, or been involved in any professional misconduct proceedings. Id. Incident reports or complaints regarding a physician become part of that physician’s credentialing file. Id. CHEM Central Credentialing Data Service (“CHEM Central”) is a department of Hallmark Health System, Inc. that performs administrative aspects of the credentialing process.

“The credentialing process at Hallmark involves the medical staff credentials committee, the medical council committee, and the board of trustees or its patient care assessment committee, each of which has been designated by Hallmark as a peer review committee.” Board of Registration in Med. v. Hallmark Health Corp., 454 Mass. at 502. The Board did not contest Hallmark’s designation of these committees as peer review committees. Id. Hallmark’s credentialing policy directly stems from the risk management and quality assurance regulations established by the Board. “Documents in a physician’s credentialing folders are generated by the credentials office and reviewed by members of the credentials committee, who send their recommendation to the medical council, which in turn makes a recommendation to the board of trustees. The board of trustees or its designee makes the final decision on credentialing.” Id. The Supreme Judicial Court recounted the factual background of this case and explained that:

At issue in this matter are the contents of Dr. Doe’s credentialing files at Hallmark for the years 2000, 2001, 2003, and 2005. All of the documents contained therein were, according to Hallmark’s chief medical officer, Dr. Mike H. Summerer, obtained in conjunction with the credentialing process at Hallmark. According to Hallmark, the files are similar in content: each contains, among other things, a letter to Dr. Doe from Hallmark regarding his application for reappointment to the Hallmark medical staff, an application for reappointment submitted by Dr. Doe, insurance information (including malpractice claims), licensing information, controlled substances certifications, and professional references and evaluations. The folders also contain Dr. Doe’s curriculum vitae and a copy of his medical license, as well as materials generated by the board, including a document regarding physician verification data and a registration renewal application for the board.

Id. at 502-03.

On August 11, 2009, the Supreme Judicial Court remanded this action to this court, “for an individualized consideration (of) whether each of the documents listed on Hallmark’s privilege log is protected by either [G.L.c. Ill, §204(a) or G.L.c. Ill, §205(b)], bearing in mind that the burden is on Hallmark to establish that each document is privileged.”2 Board of Registration in Med. v. Hallmark Health Corp., 454 Mass. at 510. The Supreme Judicial Court determined that because G.L.c. Ill, §205(b), expressly provides the Board access to credentialing documents protected under that section prior to the commencement of an adjudicatory proceeding against the physician, a previous summary judgment decision in favor of the defendants had to be vacated and the matter remanded to the Superior Court. Id. at 498-500.

On September 28, 2009, the court ordered Hallmark to submit a detailed privilege log to it, with a description of each document for which Hallmark claimed protection under either G.L.c. Ill, §204(a) or G.L.c. Ill, §205(b), and to immediately produce all subpoenaed documents to the Board for which it did not claim protection. In response, Hallmark submitted a forty-four-page privilege log dated October 8, 2009 (the “Privilege Log”), along with various attached exhibits, in an effort to establish that the documents it was still withholding were protected pursuant to the medical peer review privilege, under either G.L.c. Ill, §204(a) or G.L.c. Ill, §205(b), and were therefore, beyond the reach of the Board at this time.3 The Board acknowledges that Hallmark has released some documents for which it does not claim a privilege, but contends that it is still entitled to most of the documents set forth in Hallmark’s Privilege Log.

DISCUSSION

General Laws c. Ill, §204(a), states:

Except as otherwise provided in this section, the proceedings, reports and records of a medical peer review committee shall be confidential and ... shall not be subject to subpoena or discovery, or introduced into evidence, in any judicial or administrative proceeding, except proceedings held by the board[ ] of registration in medicine . . .

General Laws c. Ill, §205(b), provides that:

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Related

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Board of Registration in Medicine v. Hallmark Health Corp.
910 N.E.2d 898 (Massachusetts Supreme Judicial Court, 2009)
Miller v. Milton Hospital & Medical Center, Inc.
766 N.E.2d 107 (Massachusetts Appeals Court, 2002)

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Bluebook (online)
26 Mass. L. Rptr. 394, Counsel Stack Legal Research, https://law.counselstack.com/opinion/board-of-registration-in-medicine-v-hallmark-health-corp-masssuperct-2009.