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Health Care Ethics and Professionalism
- 2. The Culture of Health Care Ethics and Professionalism Lecture d This material (Comp 2 Unit 8) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 3. Ethics and Professionalism Learning Objectives • Discuss foundational concepts in medical ethics and professionalism (Lecture a). • Examine the relationships among ethical ideals, professionalism, and legal duties (Lecture a, b). • Apply the general principles of ethics and professionalism to specific topics (Lecture c, d). • Examine ethical issues in health informatics (Lecture d). 3
- 4. Ethical Issues in Health Informatics • Sources of ethical standards in health informatics • Professionalism • Representing credentials • Privacy, confidentiality, and security • Respect for patients and coworkers • Responding to unethical practices 4
- 5. Sources of Ethical Standards 8.10 Figure: Sources of ethical standards (CC-BY image by Vivian Todhunter & CAST). 5
- 6. Ethics and Law Interact • Privacy and security rules in the Health Insurance Portability and Accountability Act (HIPAA) • Health Information Technology for Economic and Clinical Health Act (HITECH) • Lawsuits and case law about failure to meet minimum professional standards 6
- 7. Professionalism • Behavior in accordance with generally accepted ideas of appropriate conduct within a specific profession • In health informatics, it includes – Knowledge of ethical requirements and ideals – Maintenance of professional skills 7
- 8. Conflicts of Interest: When Duties and Motives Clash 8.11 Figure: Conflicts of interest (CC BY-NC-SA 3.0, 2012). 8
- 9. Example of a Conflict of Interest • Patients get medical appointments in order of listing in database • Close friend is far down, asks to be moved up – Primary duty: Treat all patients fairly – Secondary motivation: Friendship • Conflicts of interest cannot always be avoided – If not, they should be disclosed to supervisor or other appropriate person 9
- 10. Represent Credentials Accurately • Report professional qualifications accurately, including – Abilities – Training – Certification – Relevant professional experience • Correct any inaccuracies regarding credentials • Report only continuing education units actually earned, and correct any inaccuracies AHIMA Code of Ethics, 2011 10
- 11. Privacy “A health information management professional shall: advocate, uphold, and defend the individual’s right to privacy and the doctrine of confidentiality in the use and disclosure of information” — AHIMA Code of Ethics “All persons have a fundamental right to privacy, and hence to control over the collection, storage, access, use, communication, manipulation and disposition of data about themselves” — IMIA Code of Ethics 11
- 12. Privacy = Confidentiality + Security • Confidentiality = Do not improperly disclose information • Security = Safeguard patient information from improper access by others • Privacy includes – Advocating for laws respecting patient privacy – Promoting these values among colleagues 12
- 13. Respect for Patients, Employers, and Coworkers Respect the inherent dignity and worth of every person • Treat each person in a respectful fashion, being mindful of individual differences and cultural and ethnic diversity • Promote the value of self-determination for each individual • Value all kinds and classes of people equitably, deal effectively with all races, cultures, disabilities, ages and genders • Ensure all voices are listened to and respected AHIMA Code of Ethics, 2011 13
- 14. Duties Owed to Patients 8.12 Figure: Duties to patients (CC BY-NC-SA 3.0, 2012). 14
- 15. Duties Owed to Patients Continued • Autonomy: “All persons have a fundamental right to self-determination” • Justice: “All persons are equal as persons and have a right to be treated accordingly” • Beneficence: “All persons have a duty to advance the good of others where the nature of this good is in keeping with the fundamental and ethically defensible values of the affected party” • Nonmaleficence: “All persons have a duty to prevent harm to other persons insofar as it lies within their power to do so without undue harm to themselves” IMIA Code of Ethics, 2011 15
- 16. Duties Owed to Patients Continued 2 • Recognize that patients have a right to know about the existence of electronic records and how they will be used • Ensure that patient data is maintained in a safe, reliable manner • Never use patients’ data for outside purposes • Treat the data of all patients with equal respect AMIA Code of Ethics, 2011 16
- 17. Duties Owed to Employers • Competence, diligence, integrity, and loyalty • Best data security measures • “Highest possible qualitative standards of data collection, storage, retrieval, processing, accessing, communication, and utilization” • “Appropriate systems for evaluating the technical, legal, and ethical acceptability of the data” IMIA Code of Ethics, 2011 17
- 18. Duties Owed to Health Care Professionals • Provide informatics services necessary for health care professionals to carry out their obligations • Provide “timely and secure access to relevant electronic records” • “Ensure the usability, integrity, and highest possible technical quality of the records” IMIA Code of Ethics, 2011 18
- 19. Responding to Unethical Practices “Health informatics professionals will refrain from impugning the reputation of colleagues but will report to the appropriate authority any unprofessional conduct by a colleague” — IMIA Code of Ethics, 2011 “A health information professional shall take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues” — AHIMA Code of Ethics, 2011 19
- 20. Whistleblowing • Duty to report can conflict with feelings of loyalty • May result in retaliation – Snubs by coworkers – Loss of promotions or raises – Physical assault • Laws may protect whistleblowers 20
- 21. Ethics and Professionalism Summary – Lecture d • Health informatics professionals have general standards of ethical behavior and professionalism • Major sources of standards come from codes of ethics written by health informatics professional societies • Health informatics professionals have four ethical duties: – Represent credentials accurately – Protect patient privacy, including confidentiality and security – Respect patients and coworkers – Respond to unethical practices by others 21
- 22. Ethics and Professionalism Summary • Professionalism requires that people act in accordance with the standards of their profession • Health care professionals must meet both ethical and legal standards • Informed consent, end-of-life issues, conflicts of interest, health care disparities, and conscientious objection are among the many difficult ethical issues faced by health care professionals • Codes of ethics provide guidance for health informatics professionals 22
- 23. Ethics and Professionalism References – Lecture d References American Health Information Management Association (AHIMA). (2011). AHIIMA code of ethics. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/ bok1_024277.hcsp?dDocName=bok1_024277 American Medical Informatics Association. (2007). Biomedical informatics core competencies. Retrieved from http://www.amia.org/biomedical-informatics-core-competencies Ethics Resource Center. (2010). Blowing the whistle on workplace misconduct. Retrieved from http://www.whistleblowers.org/storage/documents/DoddFrank/ercwhistleblowerwp.pdf Goodman, K. W., Adams, S., Berner, E. S., et al. (2013). AMIA’s code of professional and ethical conduct. Journal of the American Medical Informatics Association, 20(1), 141–143. HealthIT.gov. (2014). About ONC. Retrieved from http://www.healthit.gov/newsroom/about-onc Hurdle, J. F., Adams, S., Brokel, J., et al. (2007). A code of professional ethical conduct for AMIA. Journal of the American Medical Information Association, 14(4), 391–393. Institute of Medicine. (2012). Health IT and patient safety: Building safer systems for better care. Retrieved from http://www.nap.edu/catalog.php?record_id=13269 International Medical Informatics Association. (2011). The IMIA code of ethics for health information professionals. Retrieved from http://www.imia-medinfo.org/new2/node/39 and http://www.imia- medinfo.org/new2/pubdocs/Ethics_Eng.pdf 23
- 24. Ethics and Professionalism References – Lecture d Continued Kulikowski, C. A., Shortliffe, E. H., Currie, et al. (2012). AMIA Board white paper: Definition of biomedical informatics and specification of core competencies for graduate education in the discipline. Journal of the American Medical Informatics Association, 19(6), 931–938. Lo, B., & Field, M. J. (2009). Conflict of interest in medical research, education, and practice. National Academies Press. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK22942 Loewenstein, G., Sah, S., & Cain, D. M. (2012). The unintended consequences of conflict of interest disclosure. JAMA, 307(7), 669–670. Mannion, R., & Davies, H. T. (2015). Cultures of silence and cultures of voice: The role of whistleblowing in healthcare organisations. International Journal of Health Policy and Management, 4(8), 503. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529038 Masters, K. (2014). Health informatics ethics. In R. E. Hoyt & A. Yoshihashi (Eds.), Health informatics: Practical guide for healthcare and information technology (6th ed.), pp.195–215, S.I.: Informatics Education. Samuel H. W., Zaiane, O. R., & Sobsey, D. (2010). Towards a definition of health informatics ethics. Retrieved from https://webdocs.cs.ualberta.ca/~zaiane/postscript/ACMIHI2010.pdf 24
- 25. Ethics and Professionalism References – Lecture d Continued 2 Samuel, H. W., & Zaïane, O. R. (2014). A repository of codes of ethics and technical standards in health informatics. Online Journal of Public Health Informatics, 6(2), e189. Tables, Charts, Figures 8.10 Figure: Sources of ethical standards (CC BY CAST & Vivian Todhunter). 8.11 Figure: Conflicts of interest (CC BY-NC-SA 3.0, 2012). 8.12 Figure: Duties to patients (CC BY-NC-SA 3.0, 2012). 25
- 26. The Culture of Health Care Ethics and Professionalism Lecture d This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. 26
Editor's Notes
- No audio. Recording preparation.
- Welcome to The Culture of Health Care: Ethics and Professionalism. This is Lecture d. The component, The Culture of Health Care, addresses job expectations in health care settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
- The objectives for Ethics and Professionalism are to: Discuss foundational concepts in medical ethics and professionalism Examine the relationships among ethical ideals, professionalism, and legal duties Apply the general principles of ethics and professionalism to specific topics Examine ethical issues in health informatics
- This lecture discusses ethical issues in health informatics. Just as in the medical field as a whole, health informatics professionals face numerous, and sometimes difficult, ethical issues. After a brief discussion of professionalism, this lecture examines four ethical duties of health informatics professionals: the duty to represent credentials accurately; the duty to protect patient privacy, including the related ideas of confidentiality and security; the duty to respect patients and coworkers; and the duty to respond to unethical practices by others.
- As in other health care fields, the ethical and professional standards of the health informatics profession come from a variety of sources. Several voluntary professional organizations have developed codes of ethics, including the American Health Information Management Association, the American Medical Informatics Association, the International Medical Informatics Association, American Nursing Informatics Association, and the American Nursing Association. Other allied health care professionals may also have codes of ethics. Arms of the federal government, such as the Office of the National Coordinator for Health Information Technology, or O-N-C, have added to the body of knowledge about appropriate practices and are sources of standards of ethics and professionalism.
- There’s a back-and-forth interaction between the ethical ideals, professional standards, and legal requirements that apply to health informatics. The privacy and security rules contained in HIPAA [hip-uh], the Health Insurance Portability and Accountability Act, are part of a law but are also very important sources of professional standards. The law known as the Health Information Technology for Economic and Clinical Health Act, or HITECH [high-tek], widens the scope of privacy and security protections available under HIPAA and increases the potential legal liability for noncompliance. Health informatics law is outside the scope of this lecture; however, it’s important to remember that the law sets standards that may overlap, exceed, or even conflict with ethical duties.
- One of the ethical standards for people in health informatics is professionalism. The term professionalism refers to behaving in accordance with the generally accepted ideas of appropriate conduct within a specific profession. Obviously, it’s first necessary to know what the accepted standards of behavior are. In health informatics, one example is to become familiar with the ideas expressed in the ethical codes written by health informatics organizations. Another component of professionalism is to maintain the skills necessary to perform all work-related duties, such as taking continuing education classes.
- Another aspect of professionalism is to avoid or report conflicts of interest. To briefly review the information covered in a previous lecture, conflict of interest arises when a person is faced with a situation in which a primary interest conflicts with a secondary motivation. Primary duties include ethical and legal requirements, such as the obligation to keep patient information private. Secondary motivations are personal interests such as the opportunity for financial gain. This aspect of professionalism applies not only to those providing patient care but also to those working in informatics and information technology. Both work environments may provide access to patient information and other valuable business data assets. Hyper-diligence is needed in information technology departments and other areas not engaged in direct patient care so that staff understands the importance of confidentiality and the necessity to abide by legal and ethical requirements.
- For example, imagine a situation in which patients are supposed to receive medical appointments in the order in which their information was placed in a database. Imagine that a close friend is very far down on the list and asks to be moved up on the list. In this situation, the primary duty is to treat all patients on the list fairly. However, the personal motivation of friendship provides a strong emotional pull in the direction of making an exception for the friend. Any potential conflict of interest should be disclosed to appropriate parties. In this example, it might be appropriate to disclose to a supervisor that a friend requested preferential treatment and assure the supervisor that the proper protocol will be observed.
- The next section of this lecture examines a few of the ethical standards from the ethical codes of national and international health informatics organizations. In the Code of Ethics of the American Health Information Management Association, one of the eleven ethical principles is the obligation to accurately represent one’s credentials. Similarly, the Code of Ethics of the International Medical Informatics Association says, [quote] “Except in emergencies, health informatics professionals should only provide services in their areas of competence; however, they should always be honest and forthright about their education, experience or training.” [unquote] For example, informatics professionals should not “pad” their resumes by overstating their education, experience, or capabilities. In addition, they should correct any inaccuracies that may occur. These are duties owed to employers, patients, and the general public.
- As with many topics related to ethics, there are many different definitions of privacy. For the purpose of this lecture, privacy is defined as the patient’s right to control how his or her health information is used, and when and whether it’s disclosed. Both the American Health Information Management Association and International Medical Informatics Association place privacy in the number-one position on their lists of guiding ethical principles for health informatics professionals.
- According to several codes of ethics, the principle of respect for privacy means that health informatics professionals must keep patients’ information both confidential and secure. Confidentiality means the informatics professional will not improperly disclose the information. Security means the professional will take appropriate measures to protect the information from being inappropriately accessed by others. In addition to protecting patient information, the duty to respect privacy includes an obligation to advocate for laws about protecting patients’ health information. It also includes a duty to promote the values of confidentiality and security to colleagues.
- The Code of Ethics of the American Health Information Management Association makes a strong statement about the duties owed to others. It states that a health informatics professional should [quote] “respect the inherent dignity and worth of every person.” [unquote] The Code provides guidelines to help clarify how this lofty ideal can be put into action. Its guidelines state that all people should be treated respectfully and equitably. The duty to respect the dignity and worth of each person includes many obligations to patients, coworkers, and employers.
- The duties of a health informatics professional to patients are based on the same four core ethical principles that apply to all health care professionals: respect for autonomy, beneficence [beh-neff-fuh-sense], nonmaleficence [non-muh-leff-fuh-sense, and justice. These concepts are explained in detail in Lecture a.
- This slide explains how the four general principles are stated in the Code of Ethics of the International Medical Informatics Association. The principle of autonomy implies that all people have a fundamental right to self-determination. According to the principle of justice, all people are equal and have a right to be treated accordingly. The principle of beneficence means that all people have a duty to advance the good of others as long as the nature of that good is in keeping with ethically defensible values. The flip side of beneficence is nonmaleficence, the principle that all people have a duty to prevent harm to others insofar as they can do so without undue harm to themselves.
- The Code of Ethics of the American Medical Informatics Association says patients have the right to know about the existence of electronic records containing their personal medical data. It says informatics professionals should not mislead patients about how these data are used. They should truthfully answer all patient questions about their rights to review and revise their own medical data. In addition, informatics professionals should be helpful when a patient wishes to exercise those rights. Informatics professionals should ensure that medical data are maintained in a secure, reliable, manner. Further, the Code says medical data should never be used for purposes “outside the stated purposes, goals, or intents of the organization responsible for these data.” In addition, the data of all patients should be treated with equal care, respect, and fairness. These are just a few examples of the duties owed to patients.
- The Code of Ethics of the International Medical Informatics Association lists nine general duties that informatics professionals owe to their employers. Generally, these include competence, diligence, integrity, and loyalty. In addition, health informatics professionals must ensure that all processes are performed to the highest possible standards, and that all requirements and standards regarding security are met. The Code also says that informatics professionals should have systems for reviewing their processes and practices to make sure they are current and effective.
- In many workplaces, informatics professionals work with doctors, nurses, and other health care providers who are their coworkers, not their employers. According to the Code of Ethics of the International Medical Informatics Association, health care providers have a right to depend on the technological skills of health informatics professionals to help them meet their own professional obligations to patients. Therefore, it’s an ethical duty for informatics professionals to assist health care providers [quote] “insofar as this is compatible with the [health informatics professionals’] primary duty towards the subjects of the electronic records.” [end quote] The Code lists practical examples of these obligations. They include ensuring that health care providers have timely and secure access to useable, high-quality electronic records.
- According to the Codes of Ethics of the International Medical Informatics Association and the American Health Information Management Association, it’s not enough to simply refrain from unethical behavior. Health informatics professionals have ethical duties to discourage others from unethical behavior, to correct ethical problems when they occur, and to expose the unethical practices of others.
- People who report unethical or illegal practices are sometimes called whistleblowers. As discussed in a previous lecture, the obligation to report unethical practices can result in some challenging situations. The duty to report a coworker’s unethical behavior can result in mental or emotional conflicts about difficult issues such as loyalty. It can result in retaliation, ranging from getting the cold shoulder from coworkers to loss of promotions or raises, or even physical assault. Many laws provide protection for people who report unethical practices. However, they apply only under certain circumstances, and proving retaliation may be difficult.
- This concludes Lecture d of Ethics and Professionalism. In summary, the general standards of ethical behavior and professionalism that apply to health care providers, such as doctors and nurses, also apply to health informatics professionals. Major sources of these standards are the codes of ethics written by health informatics professional societies, such as the American Health Information Management Association, the American Medical Informatics Association, and the International Medical Informatics Association. These standards are supplemented by federal agencies such as the Office of the National Coordinator for Health Information Technology. The four ethical duties of health informatics professionals are the duty to represent credentials accurately; the duty to protect patient privacy, including the related ideas of confidentiality and security; the duty to respect patients and coworkers; and the duty to respond to unethical practices by others.
- This also concludes Ethics and Professionalism. In summary, professionalism requires individuals to maintain their work-related skills and adhere to ethical and legal standards. However, behaving ethically as an individual is not enough. A professional must also foster an ethical work environment and correct the unethical practices of others. The health care field as a whole presents many difficult ethical dilemmas, including the need for informed consent, end-of-life issues, conflicts of interest, health care disparities, and conscientious objection. The general standards of ethical behavior and professionalism that apply to health care providers, such as doctors and nurses, also apply to health informatics professionals. The standards that apply specifically to the health informatics profession come from a variety of sources. Major sources of these standards are the codes of ethics written by health informatics professional societies. According to these codes, informatics professionals are expected to demonstrate competence, diligence, integrity, and loyalty. They also have an ethical duty not only to refrain from unethical behavior but also to discourage others from unethical behavior, to correct ethical problems when they occur, and to expose the unethical practices of others.
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