Ethical & Social Issues in Health IT - Mahidol University · 62 No universal personal data privacy...

Ethical & Ethical & Ethical & Ethical & Social Social Social Social Issues in Issues in Issues in Issues in Health ITHealth ITHealth ITHealth IT

NawananTheera-Ampornpunt,

MD, PhD

Faculty of Medicine Ramathibodi Hospital

www.SlideShare.net/Nawanan

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Outline

▪ Health Care & Health IT

▪ Information Systems in Emergency Care

▪ Socio-technical Issues in Health IT

▪ Ethical Issues in Health IT

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Outline





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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

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▪ 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

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Health IT: What’s In A Word?

HealthInformationTechnology

Goal

Value-Add

Tools

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▪ Guideline adherence▪ Better documentation▪ Practitioner decision making or

process of care▪ Medication safety▪ Patient surveillance & monitoring▪ Patient education/reminder

Value of Health IT

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Outline





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EHRs / EMRs

Electronic Medical Records (EMRs)

Electronic Health Records (EHRs)

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▪ 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)

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Computerized Physician Order Entry (CPOE)

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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)

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▪ 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)

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▪ 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)

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Example of “Alerts & Reminders”

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▪ 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)

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Health Information Exchange (HIE)

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

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Biosurveillance

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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/

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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

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mHealth & Social Media in Thailand’s Flooding

▪ Situation monitoring tools (central government)

http://www.kromchol.com/

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▪ Preparedness, Educational & Advocacy Tools

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

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▪ Healthcare provider & MoPH coordination

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

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Some risks

▪ Alert fatigue

Unintended Consequences of Health IT

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Workarounds

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▪ 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

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Outline





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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

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People -Process -Technology

Technology

ProcessPeople

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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

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“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

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Health IT Successes & Failures

Kaplan & Harris-Salamone (2009)

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What makes it so hard

▪ Communication, Workflow, & Quality

▪ Difficulties of communicating across different groups makes it harder to identify requirements and understand workflow


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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


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Leviss (Editor) (2010)

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Health IT Change Management

Lorenzi & Riley (2000)

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Considerations for a successful implementation of CPOE

Ash et al. (2003)

ConsiderationsConsiderationsConsiderationsConsiderations

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

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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)

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▪ “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)

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Ash et al. (2004)

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▪ 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)

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▪ Errors in the communication and coordination proces s▪ 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)

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Campbell et al. (2006)

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Campbell et al. (2006)

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Koppel et al. (2005)

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Koppel et al. (2005)

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Outline





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� 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).

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�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

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Fundamental Theorem of Informatics

(Friedman, 2009)

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Social Media & Patient Privacy

ข้อความจริง บน

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

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�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

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Information Security

� Confidentiality� Integrity� Availability

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Health Information Security Threats

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

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� 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

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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

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Example of Social Network Policy

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...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

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�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

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� 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


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คําประกาศสทิธิของผูป้่วย

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

9. ผู้ป่วยมีสิทธิที่จะได้รับทราบข้อมูลเกี่ยวกับรักษาพยาบาลเฉพาะของตนที่ปรากฏในเวชระเบียนเมื่อร้องขอ ทั้งนี้ ข้อมูลดังกล่าวต้องไม่เป็นการละเมิดสิทธิส่วนตัวของบุคคลอื่น...”

Patients’ Bill of Rights


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�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


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▪ 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)

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▪ 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 - Mahidol University · 62 No universal personal data privacy...

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