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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
2
Outline
▪ Health Care & Health IT
▪ Information Systems in Emergency Care
▪ Socio-technical Issues in Health IT
▪ Ethical Issues in Health IT
3
Outline
▪ Health Care & Health IT
▪ Information Systems in Emergency Care
▪ Socio-technical Issues in Health IT
▪ Ethical Issues in Health IT
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
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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
▪ Health Care & Health IT
▪ Information Systems in Emergency Care
▪ Socio-technical Issues in Health IT
▪ Ethical Issues in Health IT
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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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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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▪ 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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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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mHealth & Social Media in Thailand’s Flooding
▪ Preparedness, Educational & Advocacy Tools
http://www.youtube.com/user/roosuflood
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mHealth & Social Media in Thailand’s Flooding
▪ Healthcare provider & MoPH coordination
https://www.facebook.com/groups/mophwarroomcoordination/
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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
▪ Health Care & Health IT
▪ Information Systems in Emergency Care
▪ Socio-technical Issues in Health IT
▪ Ethical Issues in Health IT
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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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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
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)
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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)
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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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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)
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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)
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Unintended Consequences of Health IT
▪ 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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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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� 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”
�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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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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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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...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
Not considered professional legal opinion
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คําประกาศสทิธิของผูป้่วย
“...7. ผู้ป่วยมีสิทธิที่จะได้รับการปกปิดข้อมูลเกี่ยวกับตนเอง จากผู้ประกอบวิชาชีพโดยเคร่งครัด เว้นแต่จะได้รับความยินยอมจากผู้ป่วยหรือการปฏิบัติหน้าที่ตามกฎหมาย...
9. ผู้ป่วยมีสิทธิที่จะได้รับทราบข้อมูลเกี่ยวกับรักษาพยาบาลเฉพาะของตนที่ปรากฏในเวชระเบียนเมื่อร้องขอ ทั้งนี้ ข้อมูลดังกล่าวต้องไม่เป็นการละเมิดสิทธิส่วนตัวของบุคคลอื่น...”
Patients’ Bill of Rights
Not considered professional legal opinion
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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
Not considered professional legal opinion
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)
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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)