The Bush administration last week proposed changing some federal rules designed to protect the confidentiality of Americans' medical records, including the ability of patients to decide in advance who should be able to use their personal health information.

The proposal would alter the requirement, put in place by the Clinton administration, that patients give their written permission before their medical records may be disclosed to doctors, hospitals, pharmacies and insurance companies. In the new requirements, those who use their records must at some point notify patients of their privacy rights.

In disclosing the modifications, Health and Human Services Secretary Tommy G. Thompson said the proposed changes "will allow us to deliver strong protections for personal medical information while improving access to care."

Last April, Bush announced that he would move ahead with the medical confidentiality regulation adopted by President Clinton, but opponents lobbied hard to change them. HHS civil rights officials said that the "very targeted changes" were intended to protect patients' privacy while simultaneously eliminating facets of the original rules that they said would interfere with patients' access to care. That reasoning essentially embraces the arguments raised by the insurance industry, which has hailed the new changes.

The administration plans to offer a relatively quick, one-month period for outside comment on the proposal before HHS administrators begin to refine it and issue a final version. The changes do not require Congressional approval.

Janlori Goldman, director of Georgetown University's Health Privacy Project, said the elimination of advance permission "cuts the legs off the privacy regulation." Sen. Edward M. Kennedy (D-Mass.) said that giving permission before personal medical information is disclosed "is central to protecting people's medical privacy." And Donald Palmisano, the American Medical Association's secretary-treasurer, said, "there is more opportunity for patient privacy to be violated now."

In one contentious change, the administration would make it easier for parents to see their children's medical records in any state that does not have a law that specifically guarantees minors their medical privacy rights. Privacy advocates are worried that the new rules will deter teenagers from seeking sensitive health services such as abortions or treatment for mental illness or STDs.

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