Welcome

The ethical concerns surrounding the ability of healthcare professionals to remotely access healthcare information are numerous. This website utilizes two animations to discuss privacy and confidentiality, equity, efficiency, and integrity as some of the issues that must be considered when healthcare informatics are employed to access electronic health information. Recommendations are reviewed for each of these ethical considerations and the ethical model for ethical decision making is also provided. The discussion and reference forums conclude this presentation.

Objectives

The learner will verbalize the four categories of ethical consideration discussed in this presentation.

The learner will understand the implications of disregarding ethical considerations in decision making.

The learner will review the violations of the Nursing Code of Ethics in relation to the animation scenario.

The learner will apply the ethical model for ethical decision making to the electronic health record in the last scenario.

Definition of EHR

Electronic health record (EHR): A computer-based data warehouse or repository of information regarding the health status of a client, replacing the former paper-based medical record; it is the systematic documentation of a client's health status and health care in a secured digital format, meaning that it can be processed, stored, transmitted, and accessed by authorized interdisciplinary professionals for the purpose of supporting efficient, high quality health care across the client's healthcare continuum (McGonigal & Mastrian, 2009, p. 450).

Authors' Position

It is the authors' view that EHRs have many benefits including providing a standard measure for providing continuity of care to patients, thereby improving their health interactions. While we are in great support of EHRs, we strongly assert that the ethical considerations discussed in this website cannot be ignored. The health information within EHRs must remain private and confidential; training to all staff that will be utilizing EHRs in any manner must  be consistent  and continued in order to ensure efficiency; equitable access must be provided and cannot be assumed; and healthcare providers must be committed to being accountable for the data within EHRs in order to maintain integrity.

Animation Scenario

We invite you to view this animation prior to reviewing the rest of the content on the webpage.

video

Animation Scenario Two

Please view before proceeding.


video

What are ethics?

"Ethics are conceptual tools used to evaluate situations and guide decision making from a moral perspective" (Simpson, 2005)

The Hippocratic Oath has been the starting point of evaluating the obligations of physicians to maintain patient privacy and confidentiality.

"What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account must be spread abroad, I will keep to myself, holding such things shameful to be spoken about" (as cited in Rothstein, 2010) 

As physicians are essential users of EHRs, we thought it relevant to include the concept of the Hippocratic Oath and the challenges EHRs may present regarding privacy and confidentiality.

Nursing Code of Ethics


The Code of Ethics as it pertains to nurses was chosen by this group as all members are Registered Nurses; we did not intend to exclude any of our colleagues by doing so.

When providing care to any persons, nurses must abide by the Code of Ethics for Registered Nurses as outlined by the Canadian Nurses Association (CNA), the national professional body for nurses across Canada.

“The code provides guidance for ethical relationships, responsibilities, behaviours and decision-making, and it is to be used in conjunction with the professional standards, laws and regulations that guide practice” (CNA, 2008, p.2).

The Code of Ethics for Registered Nurses is a set of ethical values that act as guiding principles for nursing practice. It consists of seven principles, which are outlined below. As well, various aspects of each principle are also listed.

Providing safe, compassionate, competent and ethical care (CNA, 2008)
  • Nurses are expected to conduct themselves in accordance to ethical responsibilities
  • Compassionate care is demonstrated through speech, body language and efforts to empathize with the client
  • Trustworthy relationships are considered to be the foundation of meaningful communication
  • Nurses admit mistakes and take necessary actions to prevent harm and future risks
  • Question and address unsafe, unethical, or incompetent practices

Promoting health and well-being (CNA, 2008)
  • Priority of care is directed towards the well-being of the person(s) in care
  • Advocate for the rights of the person(s)
  • Collaborate with other health-care providers to maximize health benefit for the person(s)

Promoting and respecting informed decision-making (CNA, 2008)
  • Provide information in an open, accurate, and transparent manner to person(s) in care to make informed decisions
  • Respect wishes of capable person(s) in care to decline to receive information
  • Ensure nursing care is provided with a person(s) informed consent.
  • Respect decisions made by person(s) in care regarding treatment or lifestyle

Preserving dignity (CNA, 2008)
  • All persons are to be treated with respect and the nurse supports person(s) in care in maintaining dignity and integrity
  • Unique values, customs, spiritual beliefs, social and economic circumstances are taken into consideration.
  • Respect privacy of person(s) by minimizing intrusions and providing care in a discreet manner
  • Nurses maintain appropriate professional boundaries

Maintaining privacy and confidentiality (CNA, 2008)
  • Respect the right of all individuals to have control over the collection, use, access and disclosure of their personal information
  • Take reasonable measures to prevent confidential information from being overheard
  • Collect, use and disclose health information on a need-to-know basis with the highest degree of anonymity possible and in accordance to privacy laws
  • Advocate for client access to their own health-care records
  • Respect policies that protect client(s) privacy – including safeguards in information technology

Promoting justice (CNA, 2008)
  • Do not discriminate on the basis of ANY attribute (ex. Race, gender, lifestyle, socio-economic status)
  • Refrain from utilizing negative and demeaning behaviours towards person(s) in care
  • Advocate for fair treatment and distribution of resources for person(s) in care
  • Question the status quo

Being accountable (CNA, 2008)
  • Practice in accordance to the Code of Ethics for Registered Nurses
  • Are honest and practice with integrity
  • Practice within the limits of their competence and maintain their fitness to practice
  • Identify and address conflicts of interest
  • Share knowledge and provide feedback

Ethical Considerations for Nurse Beatrice


Nurse Beatrice violated several ethical principles, identified in brackets below.

  • Accidentally discloses health information regarding a different patient to Maria Gonzalez. (Maintaining privacy and confidentiality)
  • Does not know how to correctly utilize her tablet; voices self-incompetency with tablet. (Being accountable)
  • Condescending tone “Your chart says you did have urinary incontinence” & “Well, you must have taken pills when you treated your Chlamydia infection two years ago". (Preserving dignity; Promoting justice; Providing safe, compassionate, competent and ethical care )
  • Utilizes and discloses information not pertaining to the reason of the current visit. (Maintaining privacy and confidentiality; Promoting and respecting informed decision-making; Preserving dignity)
  • Maria then states that she assumes certain aspects of her past medical record would remain private. (Maintaining privacy and confidentiality)
  • Discloses information regarding Maria’s BP only to be informed that the information is incorrect. Nurse Beatrice brushes off the incidence – states “Innocent typing errors do happen. All it takes is one slip of the finger”. (Maintaining privacy and confidentiality; Being accountable; Promoting and respecting informed decision-making; Providing safe, compassionate, competent and ethical care)
  • Maria repeatedly asks a question regarding her daughter’s lab results. It takes several attempts for Nurse Beatrice to address the question, and when she does, she provides no real answer. (Promoting health and well-being; Preserving dignity; Being accountable)
  • Assumes all individuals have the same access to computers and hence, assumes Maria may access her daughter’s results. Comes across as not able to empathize with her client, as Maria had already informed her at the beginning of the visit that she does not have a computer. (Promoting justice; Providing safe, compassionate, competent and ethical care; Promoting and respecting informed decision-making)
  • Quotes policies for privacy of information regarding Maria’s daughters’ lab results. Bureaucratic response “Doctor’s office may call our office for the results...Don’t worry...Any other questions?” (Promoting health and well-being; Promoting justice; Preserving dignity; Providing safe, compassionate, competent and ethical care)

Areas of Ethical Concern

Areas of ethical concern for patients and healthcare professionals in using EHRs that were frequently discussed in the literature were privacy and confidentiality, equity, efficiency, and integrity.

Privacy and Confidentiality

Privacy and confidentiality are the most commonly voiced concerns to using EHRs primarily because not all parties involved have legal or ethical obligations to maintain patient privacy (Wynia & Dunn, 2010).
Information within EHRs is sensitive as it could result in a continuum of consequences - anywhere from embarrassment to loss of insurance or employment (Mercuri, 2010). The author also cautioned that this risk of a breach in confidentiality when utilizing electronic health records may result in patients not fully disclosing past medical information, or worse, avoiding medical care entirely.

Privacy is also threatened by the fact that information can be easily and rapidly copied, carried, and dispersed; additionally, access controls may be insufficient or absent (Myers, Frieden, Bhenwani, & Henning, 2008).
EHRs have a number of access points that are opportunities for hackers (Conklin & McLeod, 2010). They asserted that the number of people that have access to these records only increase vulnerability and proposed an issue when one organization has sufficient security controls, others that share the same information may not. They also debated the necessity of having measures in place for emergent situations, such as multiple system sign-on, as they can be security weaknesses.

Our animation demonstrated this concept when the nurse revealed the patient's past history of a sexually transmitted infection. The historical illness was not relevant to the care the nurse was providing at the time, and the patient was alarmed that the nurse had access to this information.

Equity

As with other advanced technologies, an opportunity for disparity exists for those without access. Lack of computers or access to them, people who are not technologically savvy, those with lower literacy levels, those with decreased trust in medical professionals and systems, and non-English speaking people may suffer without supports in place (Layman, 2008; Wynia & Dunn, 2010).

In the literature reviewed, concerns that the implementation of EHRs would put vulnerable populations further at risk were raised. Layman (2008) stated there is potential for disparity not only in the way resources are provided, but also that certain groups may have inequitable public disclosure of health information. She also reported that age is a factor when considering equity as a majority of people over age 65 stated they had never gone online in a U.S. survey. These are the people that often have chronic diseases and would benefit from online communication with healthcare professionals.

Our animation reviewed this disparity when the client voiced concerns about not having money for diapers "let alone a computer". It would be a mistake to assume that technology use in electronic health records would benefit everyone. Our nurse may have made the patient defensive or embarrassed when she had to tell her that she did not have a computer or access to one.


Efficiency

Layman (2008) reported that EHRs can improve efficiency by making records more legible, complete, and accessible. Wynia and Dunn (2010) agreed, stating as long as EHRs are widely utilized, they may improve quality of care through monitoring, marketing, or tracking. However, as was seen in the animation, this is not always the case. It took the nurse time to reboot the frozen computer, to remember her log-in, and to search the right client; time that would not have lapsed with paper care records and time that could have been better spent providing care to the patient.

"It is not obvious that PHRs [personal health records] are the most efficient investment...at this time" (Wynia & Dunn, 2010, p. 71). Mercuri (2010) cautioned that outages of the EHR system would at best be an inconvenience to healthcare professionals, at worst, could contribute to morbidity and mortality rates. Worse yet, complete system failures could result in the loss of patient data.

Integrity

The Canadian Medical Protective Association (CMPA) (2009) states that physicians (and health care providers) have “…a duty to their patients to keep records that are accurate, complete and up-to-date” (p.9); Hence, the integrity of the data and the process by which this data is entered into the EHR is compromised when erroneous information is found and not corrected (CMPA, 2009).   

As noted in the animation, the nurse validates the lack of integrity of the information compiled within the EHR, as she states that incorrect data – such as the patient’s blood pressure - may accidently be entered into the system. As well, the nurse initially is quick to assume that the information regarding urinary incontinence must be correct, despite the patient’s refusal and then afterwards, realizing that the wrong patients’ data is being discussed. According to Simpson (2005), there is a tendency to assume what is in the computer is correct. CMPA (2009) also asserts that if it is noted by a HCP that information on an EHR is incorrect, the HCP must notify other users of the EHR. All erroneous information should be corrected as soon as possible.

In the animation, the nurse makes no notation of ensuring that the information ought to be corrected, nor does she state that she will follow up with having the information corrected after the visit. Layman (2008) reported studies reviewed indicated variable rates of data accuracy within electronic health records.

Recommendations

The academic literature is prolific in suggestions to minimize potential ethical dilemmas while accessing EHRs (Myers et al., 2008; Simpson, 2005; Wynia & Dunn, 2010). These recommendations are designed to support health care workers, leaders and policy creators as they face the ethical challenges of accessing electronic health records (Layman, 2008). These proposed solutions can be categorized and summarized under the areas of ethical concern discussed previously.

Privacy & Confidentiality
  • Creation and adherence to public and institution policy on the protection of remotely accessed health records. This includes policy prohibiting the long-term storage of sensitive  data on remote access devices and policy on the expunging of data appropriately (Myers et al., 2008)
  •  Establish routine disclosure protocols and verification processes (Myers et al., 2008)
  •  Employee education, including technical training and empowerment around the importance of privacy and confidentiality (Myers et al., 2008; Wynia & Dunn, 2010)
  • Encryption of data with time limited passwords or biometric technology for authentication (Layman, 2008;Myers et al., 2008)
  • Inventory control procedures and automatic deactivation policy for lost, stolen or security compromised remote devices (Myers et al, 2008)
  • Adopt the use of  wallet sized “smart cards” which activate a particular remote device (according to Myers et al., 2008 there is less likelihood of misplacing these compared to the standard remote technology)
  • Multifactor authentication process (Eg. require a PIN password and smart card; Myers et al., 2008)  
Equity
  • Education for employees and clients who use or receive information from the EHR (Myers et al., 2008; Simpson, 2005; Wynia & Dunn, 2010)
  • Targeted subsidies for those less likely to have access to EHR linked technology such as those with low literacy and socioeconomic status as well as new immigrants (Wynia & Dunn, 2010)
  • Data should never be exposed in such a way that social discrimination could result (Layman, 2008)
Efficiency
  •  Initial and continued education and technical support to ensure staff are utilizing the technology optimally and appropriately (Myers et al., 2008; Simpson, 2005)
  • Continued research to confirm the health benefits of using EHRs and techniques to reduce the costs of using EHRs (Myers et al., 2008)
  • Multiple, easy to restore back-ups of all electronic information are necessary to prevent the partial or total loss of patient records during temporary outages or program errors (Mercuri, 2010)
Integrity
  • Continued critical assessment of the data to identify human error or compromised data(Myers et al., 2008)
  •  Enhanced security networks, intranets and firewalls etc., to ensure the fidelity of the information (Layman, 2008)
  • Patient access to EHR to identify errors (Patients might pick up errors in their data if they had access; Wynia & Dunn, 2010)
Accountability
  • Healthcare professionals are concerned with being held accountable and making appropriate decisions based upon the data accessed in the EHR (Wynia & Dunn, 2010)
  • Following an ethical model for decision making, as identified by McGonigle & Mastrian (2009),  facilitates health care professionals to take the best ethical action

Ethical Model for Ethical Decision Making (McGonigle and Mastrian, 2009)

The authors discussed this model to outline a process for making ethical decisions. Every avenue must be explored and the risks and benefits must be weighed in order to decrease or prevent any harm to the people involved. With the rest of the information in this presentation, one might use the Ethical Model for Ethical Decision Making to decide if EHRs are the right choice for the population that is served through its implementation.


Examine the ethical dilemma


  • Comprehensively understand both sides of the ethical dilemma by collecting as much information as possible. Understand what needs to be decided and who the key players in the decision should be and what their views on the issue are. Examine these views and implement a plan of action that achieves the greatest good.

Thoroughly comprehend the possible alternatives

  • Brainstorm all possible alternatives available and the consequences of these decisions. Automatically rule out any alternatives that have rules that make it impossible to achieve. For all other scenarios, weigh out the best and worst case possible outcomes and decide if the risk of potential benefit outweighs any harm that could come to anyone involved.

Hypothesize ethical arguments

  • Decide which of the five approaches apply to this situation and if any of the moral principles identified will support decisions that have been done in similar circumstances. 

Investigate, compare, and evaluate the arguments for each alternative

  • Ensure that any ambiguous information is addressed and that all arguments have been explored. Rate the significance of the ethical reasoning for each choice.
    • 4 = extreme significance
    • 3 = major significance
    • 2 = significant
    • 1 = minor significance
  • Relate each of these outcomes to the values of the key players and decide which one provides the greatest good or the least harm.
  • Decide if your professional code ethical conduct supports your decision.

Choose your recommendation
  • Make a decision about the best alternative and reflect on the inclusion of the considerations of all of the key players. Look at your decision with a critical eye and try to predict what opponents might have to say.


Act on your choice
  • Implement the choice you have made. Make sure you account for all required resources to execute this plan


Look at the ethical dilemma and examine the outcomes while reflecting on the ethical decision
  • Always go back and analyze your plan and the outcome to ensure it is accomplishing what you intended. Review as necessary.

International Media Reports of Breaches in Electronic Health Records and Other Ethical Concerns

Benefits of EHRs


The Office of Health and Information Highway (2001) outline the following benefits of the implementation of EHRs:

  • support patient care and improve its quality;
  • enhance productivity of health care professionals and reduce the administrative costs associated with health care delivery and financing;
  • support clinical and health service research;
  • accomodate future developments in health care technology, policy, management, and finance
Benefits for Patients (The Office of Health and Information Highway, 2001):
  • expanded reach of effective health care
  • more secure information
  • improved sense of well-being
  • access to information about how the healthcare system works
  • improved healthcare and decreased risks (e.g. adverse drug reactions)
  • integrated health services
  • do not have to repeat basic information such as name and address
  • increased confidence knowing that all health care professionals have access to all relevant parts of their medical history
  • access to their own health records help patients to make informed decisions about their health
  • avoidance of duplicate, invasive, and/or expensive tests
  • reduced waiting lists

Benefits for Health Professionals (The Office of Health and Information Highway, 2001):
  • integrated view of patient data
  • increased access to other related and integrated patient information
  • improved access through a portal to related health services
  • improved decisions with up-to-date patient information on an as-needed basis
  • improved seamless care through coordination of multi-professional and multi-agency care
  • improved development of decision support systems

The Canadian Nurses Association (2002) Discusses EHRs' Potential Benefits for Nurses:
  • availability of comprehensive information on the care of clients/patients covering the continuum of health service delivery, across health professionals, and over time
  • convenience and ease of access, transfer, and retrieval of information
  • ability to view and display data from different views to support clinical, administrative, and research functions
  • provision of a dynamic approach to nursing research and to the development of new nursing knowledge

Canadian Media Reports of the Positive Use of EHRs



·         Manitoba pushes clinics to switch to electronic records

October 27, 2010


·         The state of electronic health records across Canada

June 30, 2009


·         E-health drug data saves $436M: study

October 6, 2009


·         Clinic’s patient records get an electronic upgrade

October 26, 2010



·         BC urged to take lead role in IT for health care

October 5, 2010


Canadian Factoids

In 2007, a survey commissioned and funded by Infoway, was conducted to shed light on Canadians opinion of EHR's and its accessibility. Canadians identified the following:
1. Personal information being accessed for mischevious/malicious reasons (45% of respondents)
2. Information may be accessed for information not pertinent to their health in the future (42% of respondents)
3.Those who access the information will not follow security and privacy protocols (37% of respondents)
4. The information may not be accurate (26% of respondents)
5. One in two Canadians are aware of the existance of EHRs (49% of respondents)
6. Canadians' comfort level with EHRs would increase if the ability to determine who was accessing their record was known. (77% of respondents)
7. Public acceptance of EHRs would grow if legislation existed making unauthorized access of records a serious criminal offence (74% of respondents)
8. Canadians would be more open to adopting the EHR if they had direct access to ensure its accuracy and mask sensitive information (68% and 55% of respondents respectively)
9. Canadians believe that recieving high quality healthcare is linked to healthcare professional's timely accessibility to patient health information (87% of respondents)
10. Public optimism in the EHR is growing! 9 in 10 support the ongoing development of the EHR (89% of respondents)
Given these survey results, healthcare professionals have a duty and responsibility to calm the concerns of the public by demonstrating ethical use when accessing the EHR. Health care professionals can demonsrtate ethical, sound decision-making when accessing EHRs to illustrate how EHRs can successfully improve the patient care experience and ultimately improve health outcomes.

Canada Health Infoway (2007). Electronic health information and privacy survey: What Canadians think-2007. Retrieved from http://www2.infoway-inforoute.ca/Documents/EKOS_Final%20report_EN.pdf

Discussions

The following are suggestions for discussions; please feel free to integrate any other relevant discussion you deem to be appropriate to the topic.

How would you feel after Nurse Bea's visit if you were patient Maria Gonzalez in the first scenario? Maria's verbal and nonverbal language illustrated her displeasure with the ethical breaches in regards to her electronic health record.

What could Nurse Bea have done differently?

Does electronic information technology change the concept of this oath? Despite not actually voicing information, the risk of security breaches is a major concern of remote access of electronic health records as the information is still at risk for dissemination.

While the authors' position is that EHR’s benefits outweigh its cons, what is your opinion?

References

Canada Health Infoway (2007). Electronic health information and privacy survey: What Canadians think-2007. Retrieved from http://www2.infoway-inforoute.ca/Documents/EKOS_Final%20report_EN.pdf
Canadian Medical Protective Association. (2009). Electronic records handbook:
Implementing and using electronic medical records (EMRs) and electronic health records (EHRs). Retrieved from http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/pdf/com_electronic_records_handbook-e.pdf
Canadian Nurses Association (2002). Demystifying the electronic health record. Nursing Now: Issues and Trends in Canadian Nursing, 13. Retrieved from http://cna-aiic.ca/CNA/documents/pdf/publications/Demystifyinghealthrecord_April2002_e.pdf Conklin, W.A., & McLeod, A. (2010). Information security foundations for the interoperability of electronic health records. International Journal of Biomedical Engineering & Technology. Retrieved from http://www.amcleod.com/mcleod11.pdf
Hadzipetros, P. (2009, June 30). The state of electronic health records across Canada.
Layman, E. (2008). Ethical issues and the electronic health record. The Health Care Manager, 27(2), 165-176. Retrieved from http://0-ovidsp.tx.ovid.com.aupac.lib.athabascau.ca/sp-3.2.3a/ovidweb.cgi?QS2=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
Mercuri, J.J. (2010). The ethics of electronic health records. Retrieved from http://www.clinicalcorrelations.org/?p=2211
Merrill, M. (2009, July 9). Virus blamed for EHR breach in Canada. Healthcare IT News. Retrieved from http://www.healthcareitnews.com/news/virus-blamed-ehr-breach-canada
Myers, J., Frieden, T.R., Bhenwani, K.M., & Henning, K.J. (2008). Privacy and public health at risk: Public health confidentiality in the digital age. American Journal of Public Health, 98(5), 793-801. Retrieved from http://0-web.ebscohost.com.aupac.lib.athabascau.ca/ehost/pdfviewer/pdfviewer?vid=2&hid=13&sid=6ee88b25-767f-4e0d-9ccc-0d9120355c99%40sessionmgr14
Nafziger, B. (2009, October 2). UNC’s health record breach raises questions about the safety of EHR. Dotmed News. Retrieved from http://www.dotmed.com/news/story/10377/?lang=en
No author. (2009, October 6). E-health drug data saves $436M: study. CBC News.

Owen, B. (2010, October 27). Manitoba pushes clinics to switch to electronic records
PHIprivacy.net. (2008). How private is your health information?  Retrieved from
Poremba, S.M. (2008, June 20). Disgruntled hacker sentenced to five years. SC Magazine: For IT Security Professionals. Retrieved from http://www.smagazineus.com/disgruntled-hacker-sentenced-to-five-years/article/111506/
Ramunni, K. (2010, March 20). Griffin hospital reports breach of dozens of patient medical records. All Business: A D&B Company. Retrieved from http://www.allbusiness.com/health-care/medical-records/14204928-1.html
Rothstein, M.A. (2010). The Hippocratic bargain and health information technology. Journal of Law, Medicine & Ethics, 38(1), 7-13. Retrieved from http://0-web.ebscohost.com.aupac.lib.athabascau.ca/ehost/pdfviewer/pdfviewer?vid=2&hid=13&sid=6449b60f-8161-46a5-ba1d-448cbe4cafbd%40sessionmgr14
Scissons, H. (2010, October 26). Clinic’s patient records get an electronic upgrade.
Shaw, Gillian. (2010, October 2010). BC urged to take lead role in IT for health care. The
Simpson, R.L. (2005). e-Ethics: New dilemmas emerge alongside new technologies. Nursing Informatics, 29(2), 179-182. Retrieved from http://0-web.ebscohost.com.aupac.lib.athabascau.ca/ehost/pdfviewer/pdfviewer?vid=2&hid=13&sid=1d665fb2-579c-431d-9678-7b4e8f3be111%40sessionmgr4
Vaas, L. (2007). Canada fumbles health data in security breach. eWeek. Retrieved from http://www.eweek.com/c/a/Security/Canada-Fumbles-Health-Data-in-Security-Breach/
Wynia, M., & Dunn, K. (2010). Dreams and nightmares: Practical and ethical issues for patients and physicians using personal health records. Journal of Law, Medicine & Ethics, 38(1), p. 64-73. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1748-720X.2010.00467.x/pdf