This document provides an overview of ethical and social issues related to health information technology. It discusses how emergency rooms have unique information needs and how health IT can provide value through functions like electronic health records and clinical decision support systems. However, it also notes there are socio-technical considerations and risks of unintended consequences to properly manage health IT implementations. The document outlines issues like ensuring user involvement, managing workflow changes and addressing communication challenges. It also discusses principles of privacy, security and informed consent as they relate to ethical use of personal health information through health IT.

1. Ethical &
Social
Issues in
Health IT
Nawanan
Theera-Ampornpunt,
MD, PhD
Faculty of Medicine
Ramathibodi Hospital
www.SlideShare.net/Nawanan

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
Outline
▪ Health Care & Health IT
▪ Information Systems in Emergency Care
▪ Socio-technical Issues in Health IT
▪ Ethical Issues in Health IT

4. 4
Health care
ER - Image Source: nj.com

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
▪ 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
Image Source: aafp.org
▪ Example: Lack of Attention
To Err Is Human

8. 8
Health IT: What’s In A Word?
Health
Information
Technology
Goal
Value-
Add
Tools

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
Outline
▪ Health Care & Health IT
▪ Information Systems in Emergency Care
▪ Socio-technical Issues in Health IT
▪ Ethical Issues in Health IT

11. 11
EHRs / EMRs
Electronic Medical
Records (EMRs)
Electronic Health
Records (EHRs)

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
Computerized Physician Order Entry (CPOE)

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
▪ 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
▪ 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
Example of “Alerts & Reminders”

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
Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

20. 20
Biosurveillance

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
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
mHealth & Social Media in
Thailand’s Flooding
▪ Situation monitoring tools (central government)
http://www.kromchol.com/

24. 24
mHealth & Social Media in
Thailand’s Flooding
▪ Preparedness, Educational & Advocacy Tools
http://www.youtube.com/user/roosuflood

25. 25
mHealth & Social Media in
Thailand’s Flooding
▪ Healthcare provider & MoPH coordination
https://www.facebook.com/groups/mophwarroomcoordination/

26. 26
Some risks
▪ Alert fatigue
Unintended Consequences of Health IT

27. 27
Workarounds

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
Outline
▪ Health Care & Health IT
▪ Information Systems in Emergency Care
▪ Socio-technical Issues in Health IT
▪ Ethical Issues in Health IT

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
People-Process-Technology
Technology
ProcessPeople

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
“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
Health IT Successes & Failures
Kaplan & Harris-Salamone (2009)

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
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
Health IT Successes & Failures
Leviss (Editor) (2010)

38. 38
Health IT Change Management
Lorenzi & Riley (2000)

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
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
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
Unintended Consequences of
Health IT
Ash et al. (2004)

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
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
Unintended Consequences of
Health IT
Campbell et al. (2006)

46. 46
Unintended Consequences of
Health IT
Campbell et al. (2006)

47. 47
Unintended Consequences of
Health IT
Koppel et al. (2005)

48. 48
Unintended Consequences of
Health IT
Koppel et al. (2005)

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
 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
 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
Fundamental Theorem of Informatics
(Friedman, 2009)

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
 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
Information Security
 Confidentiality
 Integrity
 Availability

56. 56
Health Information Security Threats
http://usatoday30.usatoday.com/life/people/2007-10-10-clooney_N.htm

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
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
Example of Social Network Policy

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
 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
 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
คําประกาศสิทธิของผู้ป่วย
“...7. ผู้ป่วยมีสิทธิที่จะได้รับการปกปิดข้อมูลเกี่ยวกับตนเอง จากผู้ประกอบ
วิชาชีพโดยเคร่งครัด เว้นแต่จะได้รับความยินยอมจากผู้ป่วยหรือการปฏิบัติ
หน้าที่ตามกฎหมาย...
9. ผู้ป่วยมีสิทธิที่จะได้รับทราบข้อมูลเกี่ยวกับรักษาพยาบาลเฉพาะของตนที่
ปรากฏในเวชระเบียนเมื่อร้องขอ ทั้งนี้ ข้อมูลดังกล่าวต้องไม่เป็นการละเมิด
สิทธิส่วนตัวของบุคคลอื่น...”
Patients’ Bill of Rights
Not considered professional legal opinion

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
▪ 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
▪ 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)