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

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

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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

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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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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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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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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
▪ 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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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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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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Health IT Successes & Failures
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)
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

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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
Ash et al. (2004)

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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 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)

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

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

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

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

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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).

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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

52. 52
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 คนไข้ฝากขอบคุณ
อาจารย์อีกครั้ง -- อีกอย่างคนไข้ช่วงนี้ไม่ค่อยสะดวก
เลยไม่ได้ไป 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 ผู้ใดจะ
นําไปเปิดเผยในประการที่น่าจะทําให้บุคคลนั้นเสียหายไม่ได้ เว้นแต่การ
เปิดเผยนั้นเป็นไปตามความประสงค์ของบุคคลนั้นโดยตรง หรือมี
กฎหมายเฉพาะบัญญัติให้ต้องเปิดเผย แต่ไม่ว่าในกรณีใด ๆ ผู้ใดจะอาศัย
อํานาจหรือสิทธิตามกฎหมายว่าด้วยข้อมูลข่าวสารของราชการหรือ
กฎหมายอื่นเพื่อขอเอกสารเกี่ยวกับข้อมูลด้านสุขภาพของบุคคลที่ไม่ใช่
ของตนไม่ได้”
Thai Privacy Laws
Not considered professional legal opinion

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คําประกาศสิทธิของผู้ป่วย
“...7. ผู้ป่วยมีสิทธิที่จะได้รับการปกปิดข้อมูลเกี่ยวกับตนเอง จากผู้ประกอบ
วิชาชีพโดยเคร่งครัด เว้นแต่จะได้รับความยินยอมจากผู้ป่วยหรือการปฏิบัติ
หน้าที่ตามกฎหมาย...
9. ผู้ป่วยมีสิทธิที่จะได้รับทราบข้อมูลเกี่ยวกับรักษาพยาบาลเฉพาะของตนที่
ปรากฏในเวชระเบียนเมื่อร้องขอ ทั้งนี้ ข้อมูลดังกล่าวต้องไม่เป็นการละเมิด
สิทธิส่วนตัวของบุคคลอื่น...”
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

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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)