How bioethics principles can aid design of electronic health records to accommodate patient granular control

The Ethical, Care, and Client-Caregiver Relationship Impacts Resulting From Introduction of Digital Communication and Surveillance Technologies in the Home Setting: Qualitative Inductive Study

BACKGROUND

Embedding communication and surveillance technology into the home health care setting has demonstrated the capacity for increased data efficiency, assumptions of convenience, and smart solutions to pressing problems such as caregiver shortages amid a rise in the aging population. The race to develop and implement these technologies within home care and public health nursing often leaves several ethical questions needing to be answered.

OBJECTIVE

The aim of this study was to understand the ethical and care implications of implementing digital communication and surveillance technologies in the home setting as perceived by health caregivers practicing in the region of Halland in Sweden with clients receiving home care services.

METHODS

A questionnaire was completed by 1260 home health caregivers and the written responses were evaluated by qualitative inductive content analysis. The researchers reviewed data independently and consensus was used to determine themes.

RESULTS

This study identified three main themes that illustrate ethical issues and unintended effects as perceived by caregivers of introducing digital communication and surveillance technologies in the home: (1) digital dependence vulnerability, (2) moral distress, and (3) interruptions to caregiving. This study highlights the consequences of technology developers and health systems leaders unintentionally ignoring the perspectives of caregivers who practice the intuitive artistry of providing care to other humans.

CONCLUSIONS

Beyond the obtrusiveness of devices and impersonal data collection designed to emphasize health care system priorities, this study discovered a multifaceted shadow side of unintended consequences that arise from misalignment between system priorities and caregiver expertise, resulting in ethical issues. To develop communication and surveillance technologies that meet the needs of all stakeholders, it is important to involve caregivers who work with clients in the development process of new health care technology to improve both the quality of life of clients and the services offered by caregivers.

The anatomy of electronic patient record ethics: a framework to guide design, development, implementation, and use

BACKGROUND

This manuscript presents a framework to guide the identification and assessment of ethical opportunities and challenges associated with electronic patient records (EPR). The framework is intended to support designers, software engineers, health service managers, and end-users to realise a responsible, robust and reliable EPR-enabled healthcare system that delivers safe, quality assured, value conscious care.

METHODS

Development of the EPR applied ethics framework was preceded by a scoping review which mapped the literature related to the ethics of EPR technology. The underlying assumption behind the framework presented in this manuscript is that ethical values can inform all stages of the EPR-lifecycle from design, through development, implementation, and practical application.

RESULTS

The framework is divided into two parts: context and core functions. The first part 'context' entails clarifying: the purpose(s) within which the EPR exists or will exist; the interested parties and their relationships; and the regulatory, codes of professional conduct and organisational policy frame of reference. Understanding the context is required before addressing the second part of the framework which focuses on EPR 'core functions' of data collection, data access, and digitally-enabled healthcare.

CONCLUSIONS

The primary objective of the EPR Applied Ethics Framework is to help identify and create value and benefits rather than to merely prevent risks. It should therefore be used to steer an EPR project to success rather than be seen as a set of inhibitory rules. The framework is adaptable to a wide range of EPR categories and can cater for new and evolving EPR-enabled healthcare priorities. It is therefore an iterative tool that should be revisited as new EPR-related state-of-affairs, capabilities or activities emerge.

Ethics and the Electronic Health Record: Description of An Integrating System of Electronic Health Records in Argentina and a Proposal to Shift Towards a Patient-Centered Conception

The Electronic Health Record (EHR) constitutes a complete information system useful for patient care, epidemiological studies and public health policies development. We describe the Integrating System of EHRs of the Autonomous City of Buenos Aires (CABA), established by Law 5669, of 2016. Although we consider the Integrating System of EHRs implemented by CABA very appropriate, we propose, first, that health services no longer store comprehensive EHRs. Instead, complete information would reside in one or several servers sheltered by civil society. Second, information would become integrated only when patients require it and grant access. The patient would now be in a position of strength (complete autonomy). Instead of asking for his data he would be asked for them. In this sense, the patient will have to exercise the emerging responsibility of reciprocity to the benefit of his own care and the care of others.

Examination and diagnosis of electronic patient records and their associated ethics: a scoping literature review

Background

Electronic patient record (EPR) technology is a key enabler for improvements to healthcare service and management. To ensure these improvements and the means to achieve them are socially and ethically desirable, careful consideration of the ethical implications of EPRs is indicated. The purpose of this scoping review was to map the literature related to the ethics of EPR technology. The literature review was conducted to catalogue the prevalent ethical terms, to describe the associated ethical challenges and opportunities, and to identify the actors involved. By doing so, it aimed to support the future development of ethics guidance in the EPR domain.

Methods

To identify journal articles debating the ethics of EPRs, Scopus, Web of Science, and PubMed academic databases were queried and yielded 123 eligible articles. The following inclusion criteria were applied: articles need to be in the English language; present normative arguments and not solely empirical research; include an abstract for software analysis; and discuss EPR technology.

Results

The medical specialty, type of information captured and stored in EPRs, their use and functionality varied widely across the included articles. Ethical terms extracted were categorised into clusters ‘privacy’, ‘autonomy’, ‘risk/benefit’, ‘human relationships’, and ‘responsibility’. The literature shows that EPR-related ethical concerns can have both positive and negative implications, and that a wide variety of actors with rights and/or responsibilities regarding the safe and ethical adoption of the technology are involved.

Conclusions

While there is considerable consensus in the literature regarding EPR-related ethical principles, some of the associated challenges and opportunities remain underdiscussed. For example, much of the debate is presented in a manner more in keeping with a traditional model of healthcare and fails to take account of the multidimensional ensemble of factors at play in the EPR era and the consequent need to redefine/modify ethical norms to align with a digitally-enabled health service. Similarly, the academic discussion focuses predominantly on bioethical values. However, approaches from digital ethics may also be helpful to identify and deliberate about current and emerging EPR-related ethical concerns.

3MD for Chronic Conditions, a Model for Motivational mHealth Design: Embedded Case Study

Background

Chronic conditions are the leading cause of death in the world. Major improvements in acute care and diagnostics have created a tendency toward the chronification of formerly terminal conditions, requiring people with these conditions to learn how to self-manage. Mobile technologies hold promise as self-management tools due to their ubiquity and cost-effectiveness. The delivery of health-related services through mobile technologies (mobile health, mHealth) has grown exponentially in recent years. However, only a fraction of these solutions take into consideration the views of relevant stakeholders such as health care professionals or even patients. The use of behavioral change models (BCMs) has proven important in developing successful health solutions, yet engaging patients remains a challenge. There is a trend in mHealth solutions called gamification that attempts to use game elements to drive user behavior and increase engagement. As it stands, designers of mHealth solutions for behavioral change in chronic conditions have no clear way of deciding what factors are relevant to consider.

Objective

The goal of this work is to discover factors for the design of mHealth solutions for chronic patients using negotiations between medical knowledge, BCMs, and gamification.

Methods

This study uses an embedded case study research methodology consisting of 4 embedded units: 1) cross-sectional studies of mHealth applications; 2) statistical analysis of gamification presence; 3) focus groups and interviews to relevant stakeholders; and 4) research through design of an mHealth solution. The data obtained was thematically analyzed to create a conceptual model for the design of mHealth solutions.

Results

The Model for Motivational Mobile-health Design (3MD) for chronic conditions guides the design of condition-oriented gamified behavioral change mHealth solutions. The main components are (1) condition specific, which describe factors that need to be adjusted and adapted for each particular chronic condition; (2) motivation related, which are factors that address how to influence behaviors in an engaging manner; and (3) technology based, which are factors that are directly connected to the technical capabilities of mobile technologies. The 3MD also provides a series of high-level illustrative design questions for designers to use and consider during the design process.

Conclusions

This work addresses a recognized gap in research and practice, and proposes a unique model that could be of use in the generation of new solutions to help chronic patients.

Generating unique IDs from patient identification data using security models

Background:

The use of electronic health records (EHRs) has continued to increase within healthcare systems in the developed and developing nations. EHRs allow for increased patient safety, grant patients easier access to their medical records, and offer a wealth of data to researchers. However, various bioethical, financial, logistical, and information security considerations must be addressed while transitioning to an EHR system. The need to encrypt private patient information for data sharing is one of the foremost challenges faced by health information technology.

Method:

We describe the usage of the message digest-5 (MD5) and secure hashing algorithm (SHA) as methods for encrypting electronic medical data. In particular, we present an application of the MD5 and SHA-1 algorithms in encrypting a composite message from private patient information.

Results:

The results show that the composite message can be used to create a unique one-way encrypted ID per patient record that can be used for data sharing.

Conclusion:

The described software tool can be used to share patient EMRs between practitioners without revealing patients identifiable data.

Power to the People: Data Citizens in the Age of Precision Medicine

Twentieth-century bioethics celebrated individual autonomy but framed autonomy largely in terms of an individual's power to make decisions and act alone. The most pressing challenges of big data science in the twenty-first century can only be resolved through collective action and common purpose. This Article surveys some of these challenges and asks how common purpose can ever emerge on the present bioethical and regulatory landscape. The solution may lie in embracing a broader concept of autonomy that empowers individuals to protect their interests by exercising meaningful rights of data citizenship. This Article argues that twentieth-century bioethics was a paternalistic, top-down affair in which self-proclaimed ethics experts set standards to protect research subjects portrayed as autonomous yet too vulnerable and disorganized to protect themselves. The time may be ripe for BioEXIT, a popular uprising of regular people seeking a meaningful voice in establishing citizen-led ethical and privacy standards to advance big-data science while addressing the concerns people feel about the privacy of their health data.

Barbarians at the Gate: Consumer-Driven Health Data Commons and the Transformation of Citizen Science

"The expression 'barbarians at the gate' was … used by the Romans to describe foreign attacks against their empire." ¹ "[It] is often used in contemporary English within a sarcastic, or ironic context, when speaking about a perceived threat from a rival group of people, often deemed to be less capable or somehow 'primitive.'" ².

Developing a Questionnaire for Iranian Women's Attitude on Medical Ethics in Vaginal Childbirth

Background:

Vaginal delivery is one of the challenging issues in medical ethics. It is important to use an appropriate instrument to assess medical ethics attitudes in normal delivery, but the lack of tool for this purpose is clear.

Objectives:

The aim of this study was to develop and validate a questionnaire for the assessment of women’s attitude on medical ethics application in normal vaginal delivery.

Patients and Methods:

This methodological study was carried out in Iran in 2013 - 2014. Medical ethics attitude in vaginal delivery questionnaire (MEAVDQ) was developed using the findings of a qualitative data obtained from a grounded theory research conducted on 20 women who had vaginal childbirth, in the first phase. Then, the validation criteria of this tool were tested by content and face validity in the second phase. Exploratory factor analysis was used for construct validity and reliability was also tested by Cronbach’s alpha coefficient in the third phase of this study. SPSS version 13 was used in this study. The sample size for construct validity was 250 females who had normal vaginal childbirth.

Results:

In the first phase of this study (tool development), by the use of four obtained categories and nine subcategories from grounded theory and literature review, three parts (98-items) of this tool were obtained (A, B and J). Part A explained the first principle of medical ethics, part B pointed to the second and third principles of medical ethics, and part J explained the fourth principle of medical ethics. After evaluating and confirming its face and content validity, 75 items remained in the questionnaire. In construct validity, by the employment of exploratory factor analysis, in parts A, B and J, 3, 7 and 3 factors were formed, respectively; and 62.8%, 64% and 51% of the total variances were explained by the obtained factors in parts A, B and J, respectively. The names of these factors in the three parts were achieved by consideration of the loading factor and medical ethics principles. The subscales of MEAVDQ showed significant reliability. In parts A, B and J, Cronbach’s alpha coefficients were 0.76, 0.72 and 0.68, respectively and for the total questionnaire, it was 0.72. The results of the test–retest were satisfactory for all the items (ICC = 0.60 - 0.95).

Conclusions:

The present study showed that the 59-item MEAVDQ was a valid and reliable questionnaire for the assessment of women’s attitudes toward medical ethics application in vaginal childbirth. This tool might assist specialists in making a judgment and plan appropriate for women in vaginal delivery management.