Week 7: Ethics, Legal, and Legislative Aspects of Nursing Informatics
Table of Contents
Review of Ethical Principles, Theory, and Approaches
The American Nurses Association (2015) provides specific guidance for ethical decision making via its Code of Ethics for Nurses with Interpretive Statements. While the document is not specific to HIT and informatics, it still provides a valuable framework that can be used when working with HIT, particularly the APN role with the following:
· Respect for human dignity
· Respect for individual right to self-determinism
· Primary commitment to the patient (defined as individual, family, group, or community)
· Advocacy for the patient
· Participation in the creation, maintenance, and improvement of healthcare environments
· Advancing the profession
· Collaboration with others to meet health needs
· Shaping social policy
Ethical Issues with HIT and Nursing Informatics
As with any paradigm shift, a new way of viewing the world brings with it some of the enduring values of the previous worldview. As health care continues its journey into digital communications, telehealth, and wearable technologies, it brings some familiar tools and skills recognized in the form of values, such as privacy, confidentiality, autonomy, and nonmaleficence. Although these basic values remain unchanged, the standards for living out these values will take on new meaning as health professionals confront new and different moral dilemmas brought on by the adoption of technological tools for information management, knowledge development, and evidence-based changes in patient care. Ethical decision-making frameworks will remain constant, but the context for examining these moral issues or ethical dilemmas will become increasingly complex.
Much of the healthcare literature addresses the potential of HIT, the need to prepare the 2020 workforce capable of working in a highly technological environment, and benefits accrued to date. Much less is written on the totality of ethical issues. A partial list of issues having an ethical component includes the following:
According to Healthit.gov (2014) Protecting Your Health Information, the privacy and security of patient health information is a top priority for patients and their families, health care providers and professionals, and the government. This was also previously discussed under HIPAA. It also requires that “key persons and organizations that handle health information to have policies and security safeguards in place to protect your health information whether it is stored on paper or electronically.” (Healthit.gov, 2014, p. 1)
Each of these three items became ethical issues because they may result in patient harm, whether that might be to reputation or physical safety. Noting discrepancies in record information without corrective action is irresponsible. Nurses need to demonstrate accountability for data integrity or risk that it may be compromised (Procter, Hayward, Heyes, Owen, & 2013). Failure to adopt technology or not using it well or as designed can also jeopardize patient safety. Failure to adopt technology for example might be an APN who continues to use written notes when automated documentation is the expectation. This deviation might be quicker and easier initially for the individual provider, but it creates a fragmented patient record, increasing the likelihood that important information will be lost, and because it is unstructured data, it is invisible for data analysis.
Proctor et al. (2013) noted that, as the largest group of caregivers, nurses at all levels have an obligation to interpret data held by their organizations to plan, deliver, and evaluate services to support patient-centered care and to actively participate in setting the technology agenda, including how patient information is collected, stored, and used. APNs have an integral role not only to the proper collection of Meaningful Use criteria, but also in defining further criteria, which will collect information that will better determine and support population-health needs and services. Perhaps the biggest ethical challenge comes when nurses fail to embrace their roles in shaping health policy and social change. Nurses need to be aware of the facts related to features of HIT legislation, particularly the Patient Protection and Affordable Care Act (ACA). ACA was intended to improve care and reduce disparities and help reform healthcare. Lachman (2012) noted distributive justice as the major ethical principal underlying health-reform initiatives.
Emerging technology will introduce new issues and dilemmas. In addition to the use of EHRs, there is a growing use of social media to market provider services and provide support. Many organizations struggle with questions surrounding proper use of social media. Genomics, or personalized medicine targeted to one’s specific genetic make-up, is an area within our grasp but still not widely known. And, technological advancements and miniaturization are quickly making nanotechnology an area that we will need to address. Nanotechnology is science, engineering, and technology that is conducted at the level of the nanoscale (nano.gov, n.d.). For reference purposes, a nanometer is equal to one billionth of a meter.
According to Healthit.gov (2018) Protecting Your Health Information, the privacy and security of PHI is a top priority for patients and their families, health care providers and professionals, and the government. This was also previously discussed under HIPAA. It also requires that key persons and organizations that handle health information to have policies and security safeguards in place to protect your health information whether it is stored on paper or electronically. (Healthit.gov, 2018, p. 1)
Confidentiality in the Modern Era
The rapid growth of social media has found many healthcare professionals unprepared to face the new challenges or to exploit the opportunities that exist with these forums. The need to maintain confidentiality presents a major obstacle to the healthcare industry’s widespread adoption of such technology; thus, social networking has not yet been fully embraced by many health professionals. Adding to the complexity of maintaining confidentiality is the increased use of mobile devices by health professionals as well as the public. Smartphones have the capability to take still pictures as well as live recordings; they have found their way into treatment rooms around the globe. Consequently, stringent confidentiality laws and more widespread availability and use of social and mobile media, numerous ethical and legal dilemmas have been posed to all healthcare workers. What are not well defined are the expectations of healthcare providers regarding this technology. In some cases, APNs have been subjected to video and audio recordings by patients and families when procedure is performed. Providers must be aware of the institutional policy regarding audio/video recording by patients and families, as well as the state laws governing two-party consent. Such laws require consent of all parties to any recording or eavesdropping activity (Lyons & Reinisch, 2013, p. 54).
Sometimes the enthusiasm for patient care and learning can lead to ethics violations. In one case, an inadvertent violation of privacy laws occurred when a nurse in a small town blogged about a child in her care whom she referred to as her “little handicapper.” The post also noted the child’s age and the fact that the child used a wheelchair. A complaint about this breach of confidentiality was reported to the Board of Nursing. A warning was issued to the nurse blogging this information, although a more stringent disciplinary action could have been taken (Spector & Kappel, 2012, p. 2).
Review the HIPAA, ARRA, and ACA legislations by clicking on each tab below.
Health Information Portability and Accountability Act (HIPAA)
HIPAA was enacted in 1996. While it is best known among consumers and healthcare professionals for its protection of personal health information (PHI) and the additional forms that each of us are asked to sign when we go to provider offices, HIPAA also ensures portability of insurance for individuals moving from one job to another, legal protection for PHI, and mandates standards for the electronic data interchange of healthcare data for encounter and claims information, and was intended to simplify the claims submission process by eliminating paper claims. HIPAA established legal sanctions for institutions and individuals who fail to protect PHI. As healthcare professionals, we are cognizant of HIPAA requirements before we share PHI via writing, electronic means, faxes, telephone, or in person. Specific measures to protect PHI include limiting record access to individuals with a right to know, signed disclosures to release information, encryption of e-mail and files, fax cover sheets, designated persons who may receive PHI, and the use of passwords to guarantee that PHI is only disclosed with persons designated by the consumer as having a right to know. HIPAA has also changed sign-in procedures for patients, disposal of forms containing PHI, and how we use whiteboards to show patient information.
Protection of PHI is the underlying reason that employees are asked to sign a statement that acknowledges that they will access electronic records solely on a need to know basis before receiving system access and that inappropriate access can result in termination of employment. An information-system safeguard to ensure that only legitimate access occurred is the electronic audit. Audit reports show all users who access an individual record and specific content viewed, making it possible to quickly establish if the record of a former spouse, another employee, or a celebrity is viewed without legitimate cause.
Previous Next Week 7: Cybersecurity and TechnologyTable of Contents
Another federal regulatory agency with a role in the privacy and security of health care data is the Food and Drug Administration (FDA). The FDA oversees the safety of medical devices, which includes addressing the management of cybersecurity risks and hospital network security. Recent guidelines issued (FDA, 2013) recommend that medical device manufacturers and health care facilities take steps to ensure that appropriate safeguards are in place to reduce the risk of failure caused by cyberattack. This could be initiated by the introduction of malware into the medical equipment or unauthorized access to configuration settings in medical devices and hospital networks. The consequences of not adequately addressing these risks could be dire. As medical devices are increasingly integrated within health care environments, there will be a need for vigilance toward cybersecurity practices to ensure all systems are adequately protected and patients remain safe from harm. Nurse Informaticists are frequently called on to evaluate safety and effectiveness of new devices and software. Considerations of cybersecurity must be included in any evaluation process.
Legislation aims to change the healthcare delivery system with the incentives, new requirements, new technology, new healthcare delivery models, and provider-patient dynamics. Significant in-roads have been made towards creating a national HIT infrastructure. We need an infrastructure that will support a birth-to-death EHR for every American that can be accessed from anywhere in the country to accommodate the needs of a mobile population. We are closer but have not yet achieved the level of health information exchange required for this to occur.
Legislation established the Office of the National Coordinator for Health Information Technology and provided incentives for the adoption of technology capable of collecting and reporting Meaningful Use criteria and of improving safety and quality of care. All healthcare professionals need to be informed of the potential that technology offers and advocate for applications that can improve the quality of care provided. Healthcare professionals need to stay informed through involvement in professional organizations and professional-education opportunities, not only as to what might be, but also of legislation and compliance issues that directly impact the way that they practice. As patient advocates, it is also important to inform patients of their rights, whether that might be the ability to restrict who has access to their PHI or that they have the right to receive an electronic form of their record. And as advocates, we also need to be aware of proposed legislation and its potential impact, and to let our elected representatives know why they should or should not support pending legislation. As healthcare providers, we have an obligation to apprise healthcare consumers of new developments, such as health information exchanges (HIEs), ACOs, and PCMHs, and what it means for them.
As nurse leaders, the APN is often in an authoritative position or perceived as a role model. For these reasons, he or she needs to determine if appropriate safeguards to protect PHI are in place, and if HIPAA requirements and other legal mandates are met. APNs also need to realize the potential that currently lies just beyond our reach as we compile huge data sets that now remain largely untapped within many separate silos. Consider how HIT legislation has positioned us to make good use of the foundation of knowledge model to acquire new knowledge, to improve our knowledge-processing capabilities, and to enable us to generate more knowledge.
Liability Concerns with Technology in Healthcare
Schaffer et al. (2017) revealed that liability claims in which EHRs were found to be a contributing factor grew from just two from 2007 through 2010 to 161 from 2011 through December 2016. One concern is that despite the potential of EHRs to advance the quality of healthcare and patient safety, there are unanticipated consequences from this rapidly adopted new technology. Review of claims revealed the following trends:
· System factors that contributed to claims—such as technology and design issues, lack of integration of hospital EHR systems, and failure or lack of alerts and alarms—increased eight percent.
· User factors—such as copy-and-paste errors, data entry errors, and alert fatigue—decreased six percent.
· More EHR-related claim events occurred in in-patient hospital rooms. However, errors also occur in private practice offices, ambulatory/day surgery centers, labor and delivery, and emergency rooms. Hospital clinics/doctors’ offices remain the top location for these events.
· Internal medicine, hospital medicine, and cardiology showed marked decreases among specialties involved in claims.
· Family medicine and nursing also showed decreases.
· Orthopedics, emergency medicine, and obstetrics/gynecology showed increases.
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Week 7: Ethics, Legal, and Legislative Aspects of Nursing Informatics