ethical & social issues in health it

Ethical & Social

Issues in Health IT

NawananTheera-Ampornpunt,

MD, PhD

Faculty of Medicine Ramathibodi Hospital

www.SlideShare.net/Nawanan

2

Outline

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

3

Outline


4

Health care

ER - Image Source: nj.com

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

▪ 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

7Image Source: aafp.org

▪ Example: Lack of Attention

To Err Is Human

8

Health IT: What’s In A Word?

HealthInformationTechnology

Goal

Value-Add

Tools

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

Outline


11

EHRs / EMRs

Electronic Medical Records (EMRs)

Electronic Health Records (EHRs)

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

Computerized Physician Order Entry (CPOE)

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

▪ 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

▪ 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

Example of “Alerts & Reminders”

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

Health Information Exchange (HIE)

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

20

Biosurveillance

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

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

mHealth & Social Media in Thailand’s Flooding

▪ Situation monitoring tools (central government)

http://www.kromchol.com/

24


▪ Preparedness, Educational & Advocacy Tools

http://www.youtube.com/user/roosuflood

25


▪ Healthcare provider & MoPH coordination

https://www.facebook.com/groups/mophwarroomcoordination/

26

Some risks▪ Alert fatigue

Unintended Consequences of Health IT

27

Workarounds

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

Outline


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

People-Process-Technology

Technology

ProcessPeople

32

Critical Success Factors in Health IT Projects

Theera-Ampornpunt (2011)

Communications of plans & progressesPhysician & non-physician user involvementAttention to workflow changesWell-executed project managementAdequate user trainingOrganizational learningOrganizational innovativeness

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

Health IT Successes & Failures

Kaplan & Harris-Salamone (2009)

35


What makes it so hard▪ Communication, Workflow, & Quality▪ Difficulties of communicating across different

groups makes it harder to identify requirements and understand workflow


36


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


37


Leviss (Editor) (2010)

38

Health IT Change Management

Lorenzi & Riley (2000)

39

Considerations for a successful implementation of CPOE

Ash et al. (2003)

ConsiderationsMotivation for implementationCPOE vision, leadership, and personnelCostsIntegration: Workflow, health care processesValue to users/Decision support systemsProject management and staging of implementationTechnologyTraining and Support 24 x 7Learning/Evaluation/Improvement

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


▪ “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


Ash et al. (2004)

43


▪ 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


▪ 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


Campbell et al. (2006)

46


Campbell et al. (2006)

47


Koppel et al. (2005)

48


Koppel et al. (2005)

49

Outline


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

Non-maleficence “First, do no harm”

BeneficenceProvide benefits to patients

Justice Fair distribution of benefits, risks & costs

Respect for AutonomyRespect decisions made and rights to make

decisions by individual persons

Relevant Ethical Principles

52

Fundamental Theorem of Informatics

(Friedman, 2009)

53

Social Media & Patient Privacy

ข้อความจริง บน

▪ "อาจารย์ครับ เมื่อวาน ผมออก OPD เจอ คุณ... คนไข้... ที่อาจารย์ผ่าไปแล้ว มา ฉายรังสีต่อที่... ตอนนี้ Happy ดี ไม่ค่อยปวด เดินได้สบาย คนไข้ฝากขอบคณุอาจารย์อีกครั้ง -- อีกอย่างคนไข้ช่วงนี้ไม่ค่อยสะดวกเลยไม่ได้ไป กทม. บอกว่าถ้าพร้อมจะไป Follow-up กับอาจารย์ครับ"

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

Information Security

Confidentiality Integrity Availability

56

Health Information Security Threats

http://usatoday30.usatoday.com/life/people/2007-10-10-clooney_N.htm

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

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

Example of Social Network Policy

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

Computer-Related Crimes Act, B.E. 2550

พรบ.การกระทําความผิดเกี่ยวกับคอมพิวเตอร์ พ.ศ. 2550 Focuses on prosecuting computer crimes &

computer-related crimesResponsibility of organizations as IT service

provider: Logging & provision of access data to authorities

Thai ICT Laws

Not considered professional legal opinion

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 ผู้ใดจะนําไปเปิดเผยในประการที่น่าจะทําให้บุคคลนั้นเสียหายไม่ได้ เว้นแต่การเปิดเผยนั้นเป็นไปตามความประสงค์ของบุคคลนั้นโดยตรง หรือมีกฎหมายเฉพาะบัญญัติให้ต้องเปิดเผย แต่ไม่ว่าในกรณีใด ๆ ผู้ใดจะอาศัยอํานาจหรือสิทธิตามกฎหมายว่าด้วยข้อมูลข่าวสารของราชการหรือกฎหมายอื่นเพื่อขอเอกสารเกี่ยวกับข้อมูลด้านสุขภาพของบุคคลที่ไม่ใช่ของตนไม่ได้”

Thai Privacy Laws


63

คําประกาศสิทธิของผู้ป่วย

“...7. ผู้ป่วยมีสิทธิที่จะได้รับการปกปิดข้อมูลเกี่ยวกับตนเอง จากผู้ประกอบวิชาชีพโดยเคร่งครัด เว้นแต่จะได้รับความยินยอมจากผู้ป่วยหรือการปฏิบัติหน้าที่ตามกฎหมาย...

9. ผู้ป่วยมีสิทธิที่จะได้รับทราบข้อมูลเกี่ยวกับรักษาพยาบาลเฉพาะของตนที่ปรากฏในเวชระเบียนเมื่อร้องขอ ทั้งนี้ ข้อมูลดังกล่าวต้องไม่เป็นการละเมิดสิทธิส่วนตัวของบุคคลอื่น...”

Patients’ Bill of Rights


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


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

▪ 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)

ethical & social issues in health it

Health & Medicine