The Overlooked Dimension of Privacy How Facility Design Compromises Confidentiality

Abstract

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Abstract

Patient privacy is a cornerstone of ethical healthcare, yet current protections, such as the Health Insurance Portability and Accountability Act (HIPAA), fail to address privacy breaches stemming from the physical and structural design of healthcare facilities. Elements such as unit names, clinic signage, and waiting room layouts can inadvertently expose sensitive information about patients, particularly those seeking care for stigmatized conditions. These structural breaches can lead to discrimination, social isolation, and avoidance of care, undermining both patient well-being and public health. Although The Joint Commission establishes standards for confidentiality, its policies do not explicitly address these design-based risks. This paper explores the ethical and psychological implications of structural privacy breaches. It argues for practical reforms, including neutral unit naming, facility redesign, expanded telehealth options, staff education, and community awareness campaigns, to better align healthcare environments with ethical standards of respect, autonomy, and confidentiality.

Introduction

Health care is inherently intimate, where patients share the most vulnerable aspects of their lives. Ensuring privacy is essential to foster trust between patients and providers^[1] and to encourage individuals to seek care without fear of judgment or discrimination. While the Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, requires healthcare entities to protect sensitive health information,^[2] it does not address privacy breaches stemming from the structural elements of healthcare facilities. The lack of patient privacy in the hospital setting is not merely about data and cybersecurity. Many patients have a valid concern about being recognized, stigmatized, and discriminated against due to hospital designs that could be improved to protect privacy.

Structural Breaches of Privacy

Despite HIPAA protections, patients are forced to give up privacy in other ways when they receive care. For instance, a hospital’s unit name can inadvertently disclose patient health information. People admitted to the “Cardiac Unit” are likely being treated for a cardiac issue, even if their specific diagnosis remains unknown. Similarly, those seen entering a fertility clinic, oncology center, or mental health facility may face assumptions about their health or personal life. This structural exposure becomes especially problematic for conditions carrying significant social stigma, such as HIV. Patients leaving an HIV clinic are often assumed to be HIV-positive, leading to potential harassment, ostracization, or even discrimination in their communities.

Impact on Vulnerable Populations

During my shadowing experiences with the Mount Sinai Human Rights Program and Columbia’s Human Rights Clinic, I listened to stories of the severe consequences of such breaches on vulnerable populations. In some countries, patients were labeled as outcasts simply for being seen at a known HIV clinic. The stigma was so severe that many patients stopped taking their medication altogether to avoid being identified, jeopardizing their health and, in some cases, their lives. This underscores how structural breaches of privacy can have deadly repercussions, particularly for marginalized individuals.

Psychological and Social Impacts

Structural privacy breaches can have long-term implications for mental health. Patients who feel exposed or stigmatized may experience anxiety or depression or avoid seeking care in the future.^[3] Adolescents, who may already be navigating identity development and social pressures, have a higher risk of negative psychological impacts. Imagine a teenager visiting a clinic with a sign advertising mental health or sexually transmitted disease services. They may face ridicule or bullying from peers, leading them to avoid seeking necessary care altogether.^[4]

Design and Technology Concerns

The issue extends beyond signs and unit naming. Consider the design of hospital spaces, such as waiting rooms or shared patient wards. Patients in certain areas of a hospital or clinic might inadvertently reveal their condition simply by being seen in that location. Even electronic sign-in systems, where patients must publicly select the reason for their visit, can contribute to breaches of privacy.

The Joint Commission’s Role and Limitations

The Joint Commission, which accredits hospitals and healthcare organizations, has established policies in its Comprehensive Accreditation Manual to address patient privacy as part of its focus on quality and safety under the Environment of Care section.^[5] For instance, its standards require measures protecting patient confidentiality, such as minimizing unnecessary disclosure of health information in public areas. The Rights and Responsibilities of the Individual chapter emphasizes that patients have a right to personal dignity, privacy, and confidentiality in all interactions.^[6] However, structural privacy breaches are not explicitly addressed in the standards. For example, while policies may limit the verbal sharing of patient information in hallways, they do not account for how unit names or facility design may inadvertently reveal sensitive information.

Balancing Specialization and Privacy

Specialized units provide undeniable benefits, such as easy access to relevant expertise and equipment, but they also leave patients with little autonomy over their privacy. Because specialized physicians and equipment are clustered in specific units instead of scattered throughout the hospital, patients must choose between being treated in a designated unit or forgoing care altogether. This lack of choice is particularly troubling in areas with limited healthcare facilities, where patients cannot seek more private alternatives. For example, a rural community might have only one clinic for sensitive services, including substance abuse, infertility, or gender-affirming care. In such cases, patients are forced to weigh their health needs against the risk of public exposure.

Constraints on Privacy

While structural privacy is a legitimate concern, it may hinder clinic function. Clear labeling and visible clinic identity play crucial roles in patient safety, operational efficiency, and equitable access to care. Healthcare institutions rely on explicit unit names to ensure that staff and emergency responders can quickly locate patients and specialized equipment. Ambiguous unit names may protect privacy, while also increasing the risk of miscommunication and care delays. Cryptic unit names can disproportionately affect patients with language barriers, worsening access and equity. They may also unintentionally reinforce the idea that these services, such as those for HIV or mental health, are shameful and must be hidden. While structural transparency is vital for safety and access, these concerns do not negate the ethical imperative to redesign healthcare spaces in ways that protect patient privacy without compromising functional efficiency.

Navigation Does Not Require Disclosure

While clear department labeling may help reduce confusion within a hospital, this benefit does not outweigh the significant privacy harms that such labels can create. In many cases, confusion can be addressed through alternative strategies, such as improved internal maps or staff-guided navigation, without publicly revealing sensitive information about the type of care a patient is receiving. The goal of preventing confusion does not require sacrificing structural privacy. Hospitals have practical tools to maintain efficiency while protecting patient confidentiality.

Privacy Privileges for the Elite

Elite individuals and celebrities often circumvent structural privacy issues by accessing forms of care that shield them from public visibility. High-profile figures routinely rely on concierge medicine, private physicians, after-hours appointments, and home-based medical services that eliminate the need to enter publicly identifiable clinics. They may also have access to discrete entrances unavailable to the public. These arrangements highlight a stark inequity: those with wealth or status can protect their medical privacy, while typical patients must navigate public clinics and visibly labeled units that may expose sensitive health information. Structural privacy should not be viewed as a luxury benefit reserved for the elite; instead, hospitals should design spaces that protect privacy as a fundamental component of equitable and dignified health care.

Ethical Imperatives and Proposed Solutions

These challenges highlight a critical dilemma in modern healthcare: hospitals strive to achieve operational efficiency without compromising patient privacy. While cost is an important factor that may limit institutions' ability to modify existing structures, it should not be a barrier when new facilities are designed with privacy in mind from the outset. Due to the Joint Commission’s standards and the ethical imperative of privacy, healthcare institutions must adopt additional measures to address structural privacy breaches. Possible solutions include redesigning publicly displayed unit names, improving overall facility design, implementing telehealth options,^[7] educating and training staff members, and instituting community awareness campaigns to address social stigma.^[8] Unit names might be redesigned as non-specific or use code names to reduce assumptions about patient conditions, such as Unit 1. Improving overall facility design can include creating private entryways or discrete waiting areas for clinics, such as HIV clinics, where patients can maintain anonymity.^[9] Clinics may also install frosted glass to maintain privacy while still monitoring patient flow. Telehealth can be a good option for sensitive consultations, so patients do not have to worry about being physically seen at the clinic.^[10] Staff members should be trained and educated on verbal confidentiality and structural privacy concerns that align with the Joint Commission standards. Community awareness campaigns can educate the public and normalize visits to healthcare facilities by decreasing the social stigma around certain conditions.

Conclusion

Healthcare institutions must prioritize not only their patients' physical health but also their psychological well-being and autonomy. Without addressing these structural privacy breaches, patients are left vulnerable to discrimination and may avoid seeking necessary care altogether. Incorporating the requirements of The Joint Commission, HIPAA, and ethical standards into structural and procedural improvements is a crucial step toward creating a truly inclusive and respectful healthcare system where patients can receive quality care without fear of privacy violations.

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^[1] AMA Code of Medical Ethics, “Privacy in Health Care,” American Medical Association, https://code-medical-ethics.ama-assn.org/ethics-opinions/privacy-health-care

^[2] 42 U.S.C. § 1320d et al., 45 C.F.R. Parts 160 and 164; Rayhan A. Tariq, Pamela B. Hackert, “Patient Confidentiality,” National Library of Medicine, published January 2023, https://www.ncbi.nlm.nih.gov/books/NBK519540/; Office for Civil Rights (OCR), “HIPPA for Professionals,” U.S Department of Health and Human Services, https://www.hhs.gov/hipaa/for-professionals/index.html; Although HIPAA is often cited as a privacy law, its original legislative priority was improving insurance portability and facilitating electronic information sharing, not establishing comprehensive patient privacy protections.

^[3] “Stigma, Prejudice and Discrimination Against People with Mental Illness,” American Psychiatric Association, https://www.psychiatry.org/patients-families/stigma-and-discrimination

^[4] “Stigma, Prejudice and Discrimination Against People with Mental Illness,” American Psychiatric Association, https://www.psychiatry.org/patients-families/stigma-and-discrimination

^[5] The Joint Commission, “Comprehensive Accreditation Manual for Hospitals,” The Joint Commission, published 2019, https://staff.codman.org/wp-content/uploads/sites/2/2021/06/JC-Accreditation-Manual-2021.pdf

^[6] The Joint Commission, “Comprehensive Accreditation Manual for Hospitals,” The Joint Commission, published 2019, https://staff.codman.org/wp-content/uploads/sites/2/2021/06/JC-Accreditation-Manual-2021.pdf

^[7] “Architecture and Privacy: Designing for Privacy in Healthcare,” HCM Architects, published March 11, 2020, https://hmcarchitects.com/news/architecture-and-privacy-designing-for-privacy-in-healthcare-2020-03-11/; “Patient privacy vs visibility: How does hospital design balance the two?,” Assa Abloy, published May 23, 2022, https://www.assaabloy.com/hk/en/stories/blogs/patient-privacy-vs-visibility-how-does-hospital-design-balance-the-two

^[8] “Stigma, Prejudice and Discrimination Against People with Mental Illness,” American Psychiatric Association, https://www.psychiatry.org/patients-families/stigma-and-discrimination; “The Impact of STDs on Mental Health: Addressing the Emotional Side of Diagnosis,” Hope Across the Globe, published April 4, 2023, https://hopeacrosstheglobe.org/the-impact-of-stds-on-mental-health/

^[9] “Architecture and Privacy: Designing for Privacy in Healthcare,” HCM Architects, published March 11, 2020, https://hmcarchitects.com/news/architecture-and-privacy-designing-for-privacy-in-healthcare-2020-03-11/; “Patient privacy vs visibility: How does hospital design balance the two?,” Assa Abloy, published May 23, 2022, https://www.assaabloy.com/hk/en/stories/blogs/patient-privacy-vs-visibility-how-does-hospital-design-balance-the-two

^[10] “Architecture and Privacy: Designing for Privacy in Healthcare,” HCM Architects, published March 11, 2020, https://hmcarchitects.com/news/architecture-and-privacy-designing-for-privacy-in-healthcare-2020-03-11/; “Patient privacy vs visibility: How does hospital design balance the two?,” Assa Abloy, published May 23, 2022, https://www.assaabloy.com/hk/en/stories/blogs/patient-privacy-vs-visibility-how-does-hospital-design-balance-the-two