Ethical & Social Issues in Health IT

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Ethical & Social Issues in Health IT

  1. 1. Ethical & Social Issues in Health IT Nawanan Theera-Ampornpunt, MD, PhD Faculty of Medicine Ramathibodi Hospital www.SlideShare.net/Nawanan
  2. 2. 2 Outline ▪ Health Care & Health IT ▪ Information Systems in Emergency Care ▪ Socio-technical Issues in Health IT ▪ Ethical Issues in Health IT
  3. 3. 3 Outline ▪ Health Care & Health IT ▪ Information Systems in Emergency Care ▪ Socio-technical Issues in Health IT ▪ Ethical Issues in Health IT
  4. 4. 4 Health care ER - Image Source: nj.com
  5. 5. ER Information Needs Patient History ▪ Problem list, comorbidities ▪ Medication list ▪ Previous visits Patient Safety ▪ Allergies Treatment-Related ▪ Drug interactions ▪ Medical references ▪ Lab & investigation results Patient Management ▪ Progress tracking ▪ Location tracking
  6. 6. 6 ▪ Limited available information ▪ Often unreliable or incomplete ▪ Unpredictable presentations ▪ Urgency - Race against time ▪ Importance of triage (separate signal from noise) ▪ Crowded ER, poor operational efficiency Problems with Information Management in ER
  7. 7. 7 Image Source: aafp.org ▪ Example: Lack of Attention To Err Is Human
  8. 8. 8 Health IT: What’s In A Word? Health Information Technology Goal Value- Add Tools
  9. 9. 9 ▪ Guideline adherence ▪ Better documentation ▪ Practitioner decision making or process of care ▪ Medication safety ▪ Patient surveillance & monitoring ▪ Patient education/reminder Value of Health IT
  10. 10. 10 Outline ▪ Health Care & Health IT ▪ Information Systems in Emergency Care ▪ Socio-technical Issues in Health IT ▪ Ethical Issues in Health IT
  11. 11. 11 EHRs / EMRs Electronic Medical Records (EMRs) Electronic Health Records (EHRs)
  12. 12. 12 ▪ Computerized Medication Order Entry ▪ Computerized Laboratory Order Entry ▪ Computerized Laboratory Results ▪ Physician Notes ▪ Patient Demographics ▪ Problem Lists ▪ Medication Lists ▪ Discharge Summaries ▪ Diagnostic Test Results ▪ Radiologic Reports Functions that Should Be Part of EHR Systems (IOM, 2003; Blumenthal et al, 2006)
  13. 13. 13 Computerized Physician Order Entry (CPOE)
  14. 14. 14 Values ▪No handwriting!!! ▪ Structured data entry: Completeness, clarity, fewer mistakes (?) ▪ No transcription errors! ▪ Entry point for CDSSs ▪ Streamlines workflow, increases efficiency Computerized Physician Order Entry (CPOE)
  15. 15. 15 ▪ The real place where most of the values of health IT can be achieved ▪ Expert systems ▪ Based on artificial intelligence, machine learning, rules, or statistics ▪ Examples: differential diagnoses, treatment options Clinical Decision Support Systems (CDSSs)
  16. 16. 16 ▪ Alerts & reminders ▪ Examples: ▪ Drug-allergy checks ▪ Drug-drug interaction checks ▪ Reminders for preventive services or certain actions (e.g. smoking cessation) ▪ Clinical practice guideline integration Clinical Decision Support Systems (CDSSs)
  17. 17. 17 Example of “Alerts & Reminders”
  18. 18. 18 ▪A dashboard of ER patients ▪Help keep track of patient status, waiting time, triage level & patient monitoring ▪Designed for timeliness & efficiency of care ER Patient Tracking (IOM, 2003; Blumenthal et al, 2006)
  19. 19. 19 Health Information Exchange (HIE) Hospital A Hospital B Clinic C Government Lab Patient at Home
  20. 20. 20 Biosurveillance
  21. 21. 21 Mobile Health (mHealth) ▪ Exponential increase in mobile devices ▪ Technology penetration in rural, underserved settings ▪ Democratization of information access ▪ Roles of social media Image Source: http://michaelcarusi.com/2012/01/01/when-you-should-not-become-a-social-media-manager/
  22. 22. 22 mHealth & Social Media in Disaster Management ▪ Communication, coordination & collaboration tools for relief workers, disaster managers, victims ▪ Used heavily in ▪ Haiti’s 2010 earthquake ▪ Japan’s 2011 earthquake & tsunami ▪ Thailand’s 2011 record flooding
  23. 23. 23 mHealth & Social Media in Thailand’s Flooding ▪ Situation monitoring tools (central government) http://www.kromchol.com/
  24. 24. 24 mHealth & Social Media in Thailand’s Flooding ▪ Preparedness, Educational & Advocacy Tools http://www.youtube.com/user/roosuflood
  25. 25. 25 mHealth & Social Media in Thailand’s Flooding ▪ Healthcare provider & MoPH coordination https://www.facebook.com/groups/mophwarroomcoordination/
  26. 26. 26 Some risks ▪ Alert fatigue Unintended Consequences of Health IT
  27. 27. 27 Workarounds
  28. 28. 28 ▪ ER has unique information needs ▪ Health IT offers values to emergency personnel ▪ Health IT has some risks (unintended consequences) ▪ The “right management” is a critical success factor Implications
  29. 29. 29 Outline ▪ Health Care & Health IT ▪ Information Systems in Emergency Care ▪ Socio-technical Issues in Health IT ▪ Ethical Issues in Health IT
  30. 30. 30 Sociotechnical Systems ▪ “An approach to complex organizational work design that recognizes the interaction between people and technology in workplaces.” (Wikipedia) ▪ “Interaction between society's complex infrastructures and human behaviour.” (Wikipedia) http://en.wikipedia.org/wiki/Sociotechnical_system
  31. 31. 31 People-Process-Technology Technology ProcessPeople
  32. 32. 32 Critical Success Factors in Health IT Projects Theera-Ampornpunt (2011) Communications of plans & progresses Physician & non-physician user involvement Attention to workflow changes Well-executed project management Adequate user training Organizational learning Organizational innovativeness
  33. 33. 33 “People & Organizational Issues” in Informatics ▪ Varied perspectives, methods, and tools from ▪ Humanities, Social science, Cognitive science ▪ Computer science and informatics ▪ Business disciplines ▪ Patient safety ▪ Workflow ▪ Collaborative work and decision-making ▪ Human-computer interaction & Usability ▪ Human factors ▪ Project and change management ▪ Adoption and diffusion of innovations ▪ Unintended consequences ▪ Policy http://www.amia.org/programs/working-groups/people-and-organizational-issues
  34. 34. 34 Health IT Successes & Failures Kaplan & Harris-Salamone (2009)
  35. 35. 35 Health IT Successes & Failures What makes it so hard ▪ Communication, Workflow, & Quality ▪ Difficulties of communicating across different groups makes it harder to identify requirements and understand workflow Kaplan & Harris-Salamone (2009)
  36. 36. 36 Health IT Successes & Failures What We Know—Lessons from Experience ▪ Provide incentives, remove disincentives ▪ Identify and mitigate risks ▪ Allow resources and time for training, exposure, and learning to input data ▪ Learn from the past and from others Kaplan & Harris-Salamone (2009)
  37. 37. 37 Health IT Successes & Failures Leviss (Editor) (2010)
  38. 38. 38 Health IT Change Management Lorenzi & Riley (2000)
  39. 39. 39 Considerations for a successful implementation of CPOE Ash et al. (2003) Considerations Motivation for implementation CPOE vision, leadership, and personnel Costs Integration: Workflow, health care processes Value to users/Decision support systems Project management and staging of implementation Technology Training and Support 24 x 7 Learning/Evaluation/Improvement
  40. 40. 40 Minimizing MD’s Change Resistance ▪ Involve physician champions ▪ Create a sense of ownership through communications & involvement ▪ Understand their values ▪ Be attentive to climate in the organization ▪ Provide adequate training & support Riley & Lorenzi (1995)
  41. 41. 41 Unintended Consequences of Health IT ▪ “Unanticipated and unwanted effect of health IT implementation” (ucguide.org) ▪ Must-read resources ▪ www.ucguide.org ▪ Ash et al. (2004) ▪ Campbell et al. (2006) ▪ Koppel et al. (2005)
  42. 42. 42 Unintended Consequences of Health IT Ash et al. (2004)
  43. 43. 43 Unintended Consequences of Health IT ▪ Errors in the process of entering and retrieving information ▪ A human-computer interface that is not suitable for a highly interruptive use context ▪ Causing cognitive overload by overemphasizing structured and “complete” information entry or retrieval ▪ Structure ▪ Fragmentation ▪ Overcompleteness Ash et al. (2004)
  44. 44. 44 Unintended Consequences of Health IT ▪ Errors in the communication and coordination process ▪ Misrepresenting collective, interactive work as a linear, clearcut, and predictable workflow ▪ Inflexibility ▪ Urgency ▪ Workarounds ▪ Transfers of patients ▪ Misrepresenting communication as information transfer ▪ Loss of communication ▪ Loss of feedback ▪ Decision support overload ▪ Catching errors Ash et al. (2004)
  45. 45. 45 Unintended Consequences of Health IT Campbell et al. (2006)
  46. 46. 46 Unintended Consequences of Health IT Campbell et al. (2006)
  47. 47. 47 Unintended Consequences of Health IT Koppel et al. (2005)
  48. 48. 48 Unintended Consequences of Health IT Koppel et al. (2005)
  49. 49. 49 Outline ▪ Health Care & Health IT ▪ Information Systems in Emergency Care ▪ Socio-technical Issues in Health IT ▪ Ethical Issues in Health IT
  50. 50. 50  Leads to patient outcomes, including deaths  Information risks  Research ethics  Informatics practitioners as “professionals” with specific skills, training, & competencies?  Most common question “Who owns the data?” Why Ethics Is Important in Informatics? Goodman & Miller. Chapter 10: Ethics and Health Informatics: Users, Standards, and Outcomes. In Shortliffe (3rd Edition).
  51. 51. 51  Non-maleficence  “First, do no harm”  Beneficence  Provide benefits to patients  Justice  Fair distribution of benefits, risks & costs  Respect for Autonomy  Respect decisions made and rights to make decisions by individual persons Relevant Ethical Principles
  52. 52. 52 Fundamental Theorem of Informatics (Friedman, 2009)
  53. 53. 53 Social Media & Patient Privacy ข้อความจริง บน ▪"อาจารย์ครับ เมื่อวาน ผมออก OPD เจอ คุณ... คนไข้ ... ที่อาจารย์ผ่าไปแล้ว มา ฉายรังสีต่อที่... ตอนนี้ Happy ดี ไม่ค่อยปวด เดินได้สบาย คนไข้ฝากขอบคุณ อาจารย์อีกครั้ง -- อีกอย่างคนไข้ช่วงนี้ไม่ค่อยสะดวก เลยไม่ได้ไป กทม. บอกว่าถ้าพร้อมจะไป Follow-up กับอาจารย์ครับ"
  54. 54. 54  Privacy: “The ability of an individual or group to seclude themselves or information about themselves and thereby reveal themselves selectively.” (Wikipedia)  Information Security: “Protecting information and information systems from unauthorized access, use, disclosure, disruption, modification, perusal, inspection, recording or destruction” (Wikipedia) Privacy & Security
  55. 55. 55 Information Security  Confidentiality  Integrity  Availability
  56. 56. 56 Health Information Security Threats http://usatoday30.usatoday.com/life/people/2007-10-10-clooney_N.htm
  57. 57. 57  Physical Security  System Security  Antivirus, Firewall, Intrusion Detection/Prevention System, Log files, Monitoring  Software Security  Network Security  Database Security  User Security  User account management  Education against phishing/social engineering  Encryption Security Safeguards
  58. 58. 58 Privacy Safeguards Image: http://www.nurseweek.com/news/images/privacy.jpg  Security safeguards  Informed consent  Privacy culture  User awareness building & education  Organizational policy & regulations  Enforcement  Ongoing privacy & security assessments, monitoring, and protection
  59. 59. 59 Example of Social Network Policy
  60. 60. 60 ... What I may see or hear in the course of treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep myself holding such things shameful to be spoken about. ... http://en.wikipedia.org/wiki/Hippocratic_Oath Hippocratic Oath
  61. 61. 61  Computer-Related Crimes Act, B.E. 2550 พรบ.การกระทําความผิดเกี่ยวกับคอมพิวเตอร์ พ.ศ. 2550  Focuses on prosecuting computer crimes & computer-related crimes  Responsibility of organizations as IT service provider: Logging & provision of access data to authorities Thai ICT Laws Not considered professional legal opinion
  62. 62. 62  No universal personal data privacy law (Draft law has been proposed)  National Health Act, B.E. 2550 พรบ.สุขภาพแห่งชาติ พ.ศ. 2550 “มาตรา 7 ข้อมูลด้านสุขภาพของบุคคล เป็นความลับส่วนบุคคล ผู้ใดจะ นําไปเปิดเผยในประการที่น่าจะทําให้บุคคลนั้นเสียหายไม่ได้ เว้นแต่การ เปิดเผยนั้นเป็นไปตามความประสงค์ของบุคคลนั้นโดยตรง หรือมี กฎหมายเฉพาะบัญญัติให้ต้องเปิดเผย แต่ไม่ว่าในกรณีใด ๆ ผู้ใดจะอาศัย อํานาจหรือสิทธิตามกฎหมายว่าด้วยข้อมูลข่าวสารของราชการหรือ กฎหมายอื่นเพื่อขอเอกสารเกี่ยวกับข้อมูลด้านสุขภาพของบุคคลที่ไม่ใช่ ของตนไม่ได้” Thai Privacy Laws Not considered professional legal opinion
  63. 63. 63 คําประกาศสิทธิของผู้ป่วย “...7. ผู้ป่วยมีสิทธิที่จะได้รับการปกปิดข้อมูลเกี่ยวกับตนเอง จากผู้ประกอบ วิชาชีพโดยเคร่งครัด เว้นแต่จะได้รับความยินยอมจากผู้ป่วยหรือการปฏิบัติ หน้าที่ตามกฎหมาย... 9. ผู้ป่วยมีสิทธิที่จะได้รับทราบข้อมูลเกี่ยวกับรักษาพยาบาลเฉพาะของตนที่ ปรากฏในเวชระเบียนเมื่อร้องขอ ทั้งนี้ ข้อมูลดังกล่าวต้องไม่เป็นการละเมิด สิทธิส่วนตัวของบุคคลอื่น...” Patients’ Bill of Rights Not considered professional legal opinion
  64. 64. 64  Electronic Transactions Acts, B.E. 2544 & 2551 พรบ.ว่าด้วยธุรกรรมทางอิเล็กทรอนิกส์ พ.ศ. 2544 และ พรบ.ว่าด้วยธุรกรรมทางอิเล็กทรอนิกส์ (ฉบับที่ 2) พ.ศ. 2551  Legal binding of electronic transactions and electronic signatures  Security & privacy requirements for  Determining legal validity & integrity of electronic transactions and documents, print-outs, & paper-to-electronic conversions  Governmental & public organizations  Critical infrastructures Thai ICT Laws Not considered professional legal opinion
  65. 65. 65 ▪ Health IT offers values to emergency personnel ▪ Health IT has some risks (unintended consequences) ▪ Alert fatigue ▪ Work-arounds ▪ Mistakes from using IT ▪ Poor user interfaces ▪ Privacy & security risks Summary (1)
  66. 66. 66 ▪ Attention to “People-Process-Technology” balance is important to prevent unintended consequences ▪ Certain uses of health IT have ethical issues. ▪ Balance risks vs. benefits ▪ IT vs. humans ▪ Privacy risks ▪ Social media use ▪ Ethical principles and laws help guide what should be done. Summary (2)

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