Privacy and confidentiality in emergency medicine: obligations and challenges

Privacy and confidentiality of emergency department patient information: Contemporary considerations and challenges

This article provides a brief review of moral and legal duties to respect confidentiality in emergency medicine. The article considers current challenges to confidentiality in emergency departments and proposes strategies to address them. It is offered as an update of the two-part review of confidentiality in emergency medicine in 2005 by Moskop et al published in 2005 in Annals of Emergency Medicine.

Ethical challenges in obstetric emergencies in low- and middle-income countries

Obstetric emergencies are challenging, requiring implementation of a rapid sequence of interventions in a very short time to optimize clinical outcome. Managing obstetric emergencies could evoke ethical dilemmas for the obstetrician because of limited time to adequately educate the patient about her condition; impaired consciousness of the patient to give consent; nonexistent prior patient -doctor relationship and the need to consider both the patient and the fetus. In Low- and middle-income countries (LMICs), poor access to appropriate emergency care, structural and financial barriers and a largely uneducated and a deeply cultural population contribute to the ethical challenges. In this article we review key ethical issues in obstetric emergencies in LMICs such as informed consent, refusal of life saving treatment, confidentiality, disclosure of patient medical information and discharge against medical advice. The duties and responsibilities of the state to disadvantaged pregnant women and the ethical imperative of the obstetrician to provide care under these circumstances are discussed.

Origin of Antibiotics and Antibiotic Resistance, and Their Impacts on Drug Development: A Narrative Review

Antibiotics have revolutionized medicine, saving countless lives since their discovery in the early 20th century. However, the origin of antibiotics is now overshadowed by the alarming rise in antibiotic resistance. This global crisis stems from the relentless adaptability of microorganisms, driven by misuse and overuse of antibiotics. This article explores the origin of antibiotics and the subsequent emergence of antibiotic resistance. It delves into the mechanisms employed by bacteria to develop resistance, highlighting the dire consequences of drug resistance, including compromised patient care, increased mortality rates, and escalating healthcare costs. The article elucidates the latest strategies against drug-resistant microorganisms, encompassing innovative approaches such as phage therapy, CRISPR-Cas9 technology, and the exploration of natural compounds. Moreover, it examines the profound impact of antibiotic resistance on drug development, rendering the pursuit of new antibiotics economically challenging. The limitations and challenges in developing novel antibiotics are discussed, along with hurdles in the regulatory process that hinder progress in this critical field. Proposals for modifying the regulatory process to facilitate antibiotic development are presented. The withdrawal of major pharmaceutical firms from antibiotic research is examined, along with potential strategies to re-engage their interest. The article also outlines initiatives to overcome economic challenges and incentivize antibiotic development, emphasizing international collaborations and partnerships. Finally, the article sheds light on government-led initiatives against antibiotic resistance, with a specific focus on the Middle East. It discusses the proactive measures taken by governments in the region, such as Saudi Arabia and the United Arab Emirates, to combat this global threat. In the face of antibiotic resistance, a multifaceted approach is imperative. This article provides valuable insights into the complex landscape of antibiotic development, regulatory challenges, and collaborative efforts required to ensure a future where antibiotics remain effective tools in safeguarding public health.

Law Enforcement and Patient Privacy Among Survivors of Violence: A Nationwide Mixed-Methods Study

INTRODUCTION

During the emergent treatment of violently injured patients, law enforcement (LE) officers and health care providers frequently interact. Both have duties to protect patient health, rights, and public health, however, the balance of these duties may feel at odds. The purpose of this study is to assess hospital-based violence intervention program (HVIP) representatives' experiences with LE officers among survivors of violence and the impact of hospital policies on interactions with LE officers.

MATERIALS AND METHODS

A nationwide survey was distributed to the 35 HVIPs that form the Health Alliance for Violence Intervention. Data regarding respondent affiliation, programs, and perceptions of hospital policies outlining LE activity were collected. Follow-up video interviews were open coded and qualitatively analyzed using grounded theory.

RESULTS

Respondents from 32 HVIPs completed the survey (91%), and 22 interviews (63%) were conducted. Common themes from interviews were: police-patient interactions; racism, bias, and victims' treatment as suspects; and training and education. Only 39% of respondents knew that policies existed and were familiar with them. Most representatives believed their hospitals' existing policies were inadequate, ineffective, or biased. Programs that reported good working relationships with LE officers offered insight on how their programs maintain these partnerships and work with LE officers towards a common goal.

CONCLUSIONS

Unclear or inadequate policies relating to LE activity may jeopardize the health and privacy of violently injured patients. Primary areas identified for improvement include clarifying and revising hospital policies, education of staff and LE officers, and improved communication between health care providers and LE officers to better protect patient rights.

Behind open doors: Patient privacy and the impact of design in primary health care, a qualitative study in Indonesia

Background

The importance and attention to patient privacy in recent decades have been directed mostly toward medical data protection in electronic means. Hence, other aspects of patients' privacy were overlooked, particularly in the primary health care (PHC) level. In the attempt of many countries, including Indonesia, to strive toward universal healthcare provision, a strong and accessible PHC is essential. This situation may create a tension in privacy provision where patients who need to disclose secrets may opt for other facilities, such as hospitals. This study aimed to describe and discuss patients' and doctors' perspectives and experiences about privacy in PHC in Indonesia, particularly since the universal coverage started.

Design and methods

We used in-depth interviews and observations to gather information. Inductive and thematic data analyses were conducted. We interviewed PHC users (n = 17), doctors (n = 16), other PHC staff (n = 7), and non-PHC users (n = 5) and observed the PHC activities.

Results

We found that privacy is imperative for both patients and doctors. Design and conditions in PHC, including consultation room doors open, separate rooms for treatment, and patients' symptoms asked by other staff were aspects that undermine privacy in PHC. Inadequate physical and informational privacy protection during a patient's visit has affected the quality of care negatively in ways that impede proper anamneses and physical examination.

Conclusion

Ensuring patients' and doctors' physical and informational privacy is essential to creating PHC as the primary source of care that responds to the privacy values of its users, but it has been overlooked. The PHC building designs and care provision guidelines should incorporate the privacy needs of patients and doctors.

Knowledge, practices, and patterns of data confidentiality among pharmacists in a developing country

Background

Increased application of electronic health information systems led to the buildup of patient information and facilitated access to this data. Consequently, the confidentiality of this information became an ethical challenge to medical teams' members including pharmacists. However, no study has been conducted to assess pharmacists' knowledge or practices of data confidentiality. Thus, the aim of this study was to assess the current practices and knowledge of pharmacists concerning data confidentiality.

Methods

This was a cross sectional study that included clinical pharmacists in tertiary hospitals and health care centers in Jordan. Data was collected through phone or face to face interviews using a data collection sheet. All continuous data was presented as median ± interquartile range (IQR) and categorical data as frequency (%). One way Chi square was used to check significant differences among categorical groups. Predictors that may affect knowledge and behavior scores were screened using simple linear regression.

Results

A total of 388 pharmacists were interviewed with a mean age of 39.59 ± 8.32 years, with an average experience of 12.55 ± 7.30 years. Pharmacists relied on their personal experience to resolve ethical dilemmas (n = 274, 70.3%), and when they seek advice, their work colleagues (n = 180, 46.4%) %), followed by the head of departments (144 n; 37.1%), were the main source of advice on ethical issues. The overall median knowledge score of pharmacists about data confidentiality was 2.0 out of 5.0 (IQR = 2.0). A considerable percentage of the pharmacists was willing to share information with family members without asking for permission from the patient (n = 98, 25.3%). Pharmacists had a median behavior score of 3.5 out of 4.0 (IQR = 0.4) regarding practices related to data confidentiality, where the majority of them handled medical information from the patient with great confidentiality (304 n, 78.4%), and 85.8% of them (n = 333) gave patient's sexual diseases-related medical information the highest confidentiality. However, based on univariate and multivariate linear regression analysis, none of the examined sociodemographic variables significantly predicted pharmacists' knowledge or behaviors (P > 0.05).

Conclusion

Pharmacists are aware of the importance of confidentiality issues of their patients. However, a number of gaps in their knowledge and practices of data confidentiality were identified. Training that targets these gaps in their knowledge, and rectifies incorrect practices is needed during university education and as part of their continuous medical education.

Differential privacy for public health data: An innovative tool to optimize information sharing while protecting data confidentiality

Coronavirus disease 2019 (COVID-19) has highlighted the need for the timely collection and sharing of public health data. It is important that data sharing is balanced with protecting confidentiality. Here we discuss an innovative mechanism to protect health data, called differential privacy. Differential privacy is a mathematically rigorous definition of privacy that aims to protect against all possible adversaries. In layperson's terms, statistical noise is applied to the data so that overall patterns can be described, but data on individuals are unlikely to be extracted. One of the first use cases for health data in Australia is the development of the COVID-19 Real-Time Information System for Preparedness and Epidemic Response (CRISPER), which provides proof of concept for the use of this technology in the health sector. If successful, this will benefit future sharing of public health data.

Differential privacy is an innovative technique that can be applied to data to protect confidentiality. This has been used primarily to protect private sector data, but has significant implications for public health. We describe the methods of differential privacy in terms understandable to a non-computer-science audience. To our knowledge, this is the first article describing differential privacy in language and context appropriate for a health audience. The case study described shows the feasibility of the use of differential privacy for public health surveillance data to optimize information sharing while protecting data confidentiality. This method allows for data to be released in more granular detail in terms of time, place, and person without compromising privacy and confidentiality. Future research needs to consider other use cases, including a range of surveillance systems and applications in other types of health data.

The informational privacy of patients in prehospital emergency care-Integrative literature review

AIMS AND OBJECTIVES

To explore the informational privacy of patients in prehospital emergency care based on the existing literature.

BACKGROUND

Informational privacy, a central value in health care, is strongly connected to patients' safety and quality of care. However, its realisation faces challenges in the unique context of prehospital emergency care.

DESIGN

Integrative literature review.

METHODS

Systematic searches of the CINAHL, MEDLINE and Cochrane library databases (n = 1588) and a manual search of the reference lists of the included articles (n = 0) were conducted in August 2019. In the article selection, specified inclusion and exclusion criteria were used. Two Joanna Briggs Institute quality appraisal tools were used. Ultimately, 11 studies were included. Analysis was conducted by using content analysis. Overall, process of the review was guided by PRISMA checklist.

RESULTS

The number of primary research studies related to informational privacy in prehospital emergency care is limited and mainly focused on privacy and confidentiality. The informational privacy was described from three aspects (a) information control by patients, (b) information protection by healthcare professional and (c) concepts related to informational privacy. The realisation of patients' informational privacy varied. Factors related to the realisation were related to the paramedics, the prehospital emergency care work and the patients.

CONCLUSION

More research specifically focused on informational privacy in prehospital emergency care is needed. Paramedics' understanding of informational privacy and its protection is essential to enhance the realisation of patients' informational privacy. Therefore, a response is required to their need for more education concerning informational privacy.

RELEVANCE TO CLINICAL PRACTICE

Paramedics' attention should be drawn to the identified factors related to the realisation of informational privacy and its use in clinical practice in order to continue to provide high-quality prehospital emergency care.

Confidentiality and Capacity

This article focuses on confidentiality and capacity issues affecting patients receiving care in the emergency department. The patient-physician relationship begins with presumed confidentiality. The article also clarifies instances where a physician may be required to break confidentiality for the safety of patients or others. This article then discusses risk management issues relevant to determining a patient's capacity to accept or decline medical care in the emergency department setting. Situations pertaining to refusal of care and discharges against medical advice are examined in detail, and best practices for mitigating risk in informed consent and barriers to consent are reviewed.

Patient's informational privacy in prehospital emergency care: Paramedics' perspective

BACKGROUND

As a fundamental human right in healthcare, informational privacy creates the foundation for patient's safety and the quality of care. However, its realization can be a challenge in prehospital emergency care, considering the nature of the work.

OBJECTIVES

To describe patient's informational privacy, its realization, and the factors related to the realization in prehospital emergency care from the perspective of paramedics.

RESEARCH DESIGN

A descriptive questionnaire study was conducted. The data were analyzed with inductive content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

The participants (n = 26) were paramedics in one of the 22 rescue departments in Finland.

ETHICAL CONSIDERATIONS

The study received ethical approval from the ethics committee of the University of Turku (Finland). Permission for the study was given by the collaborating rescue department.

FINDINGS

Paramedics described patient's informational privacy as patients' right to their own health records, as protection of the patient's health records, and as comprehensive respect of the patient's privacy by the persons involved in the patient's care. In general, informational privacy was described as being realized regarding confidentiality, reporting, and maintaining the patient's health records. However, it was also described as being dependent on the context, and some areas in need of improvement were identified. Promoting and preventing factors related to the realization were also identified. The promoting factors were paramedics' professional activity, environment, training, and guidelines. The preventing factors were the nature of the work, paramedics' attitudes, and the lack of knowledge concerning informational privacy among paramedics, the collaborating authority, patients, and relatives.

DISCUSSION AND CONCLUSION

Paramedics had a multidimensional understanding of informational privacy and the factors related to its realization. However, its realization varies, and more research and education are therefore needed to enhance the realization and to provide equal and high-quality care for all the patients in prehospital emergency care.

A Qualitative Study of the Theory Behind the Chairs: Balancing Lean-Accelerated Patient Flow With the Need for Privacy and Confidentiality in an Emergency Medicine Setting

Background

Many emergency departments (EDs) have used the Lean methodology to guide the restructuring of their practice environments and patient care processes. Despite research cautioning that the layout and design of treatment areas can increase patients’ vulnerability to privacy breaches, evaluations of Lean interventions have ignored the potential impact of these on patients’ informational and physical privacy. If professional regulatory organizations are going to require that nurses and physicians interact with their patients privately and confidentially, we need to examine the degrees to which their practice environment supports them to do so.

Objective

This study explored how a Lean intervention impacted the ability of emergency medicine physicians and nurses to optimize conditions of privacy and confidentiality for patients under their care.

Methods

From July to December 2017, semistructured interviews were iteratively conducted with health care professionals practicing emergency medicine at a single teaching hospital in Ontario, Canada. The hospital has 1000 beds, and approximately 128,000 patients visit its 2 EDs annually. In response to poor wait times, in 2013, the hospital’s 2 EDs underwent a Lean redesign. As the interviews proceeded, information from their transcripts was first coded into topics and then organized into themes. Data collection continued to theoretical sufficiency.

Results

Overall, 15 nurses and 5 physicians were interviewed. A major component of the Lean intervention was the construction of a three-zone front cell at both sites. Each zone was outfitted with a set of chairs in an open concept configuration. Although, in theory, professionals perceived value in having the chairs, in practice, these served multiple, and often, competing uses by patients, family members, and visitors. In an attempt to work around limitations they encountered and keep patients flowing, professionals often needed to move a patient out from a front chair and actively search for another location that better protected individuals’ informational and physical privacy.

Conclusions

To our knowledge, this is the first qualitative study of the impact of a Lean intervention on patient privacy and confidentiality. The physical configuration of the front cell often intensified the clinical work of professionals because they needed to actively search for spaces better affording privacy and confidentiality for patient encounters. These searches likely increased clinical time and added to these patients’ length of stay. We advocate that the physical structure and configuration of the front cell should be re-examined under the lens of Lean’s principle of value-added activities. Future exploration of the perspectives of patients, family members, and visitors regarding the relative importance of privacy and confidentiality during emergency care is warranted.

Experiences of pre-hospital emergency medical personnel in ethical decision-making: a qualitative study

Background

Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service (EMS) personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have to deal with every day, ethical decision-making (EDM) has become an inevitable challenge.

Methods

The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method.

Results

The process of data analysis resulted in the emergence of 3 main categories “respecting client’s values”, “performing tasks within the professional manner”, “personal characteristic”, and the emergence of eight (8) sub-categories signifying participants’ experiences with regard to EDM.

Conclusion

According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client’s values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties.

Ethical decision-making based on field assessment: The experiences of prehospital personnel

INTRODUCTION

Due to the stressful nature of prehospital emergency providers' duties, as well as difficulties such as distance to information resources and insufficient time to analyze situations, ethical decision-making in prehospital services is a daily challenge.

OBJECTIVES

This study aimed to describe the experiences of Iranian prehospital emergency personnel in the field of ethical decision-making.

METHODS

The data were collected by semi-structured interviews (n = 15) in Iran and analyzed using the content analysis approach.

ETHICAL CONSIDERATIONS

This study was conducted in accordance with the principles of research ethics and national rules and regulations relating to informed consent and confidentiality.

RESULTS

The results obtained were categorized into three main categories that included "assessment of the scene atmosphere, assessment of patients' condition and their family, and predicting outcomes of decision-making." The central category was "field assessment," which demonstrated the strategy of ethical decision-making by prehospital providers when facing ethical conflicts.

CONCLUSION

Although findings showed that the majority of prehospital providers make ethical decisions based on the patients' benefit, they also consider consequences of their decisions in dealing with personal and professional threats. This article identifies and describes a number of ethical values of prehospital providers and discusses how the values may be considered by paramedics when facing ethical conflicts.

Nurses’ and patients’ perceptions of privacy protection behaviours and information provision

Background:

With increased attention to patient privacy and autonomy, privacy protection and information provision for patients are becoming increasingly important.

Objectives:

The aim of this study was to identify and analyse nurses’ and patients’ perceptions of the importance and performance of protecting patients’ privacy and providing them with relevant information.

Research design:

This study is a descriptive cross-sectional investigation. Participants and research context: Participants were 168 patients hospitalised in medical and surgical wards and 176 nurses who cared for them.

Ethical consideration:

This study was approved by the Chung-Ang University Bioethics Committee, and informed written consent was collected from all participants.

Findings:

Nurses’ recognition of the importance of protecting patients’ privacy and providing adequate information was higher compared to their actual performance, and the nurses’ level of performance was higher in comparison with the patients’ recognition of its importance.

Discussion:

Although a holistic approach to patient privacy protection and information provision is needed, the medical field has not embraced this model of care.

Conclusions:

These findings provide empirical data to create an ethical environment for the future, as considerable attention has been devoted to patients’ rights and medical institutions’ liability for providing explanations to patients.

The Impact of Genetic Testing and Genetic Information on Ethical, Legal and Social Issues in North America

This chapter discusses the impact of genetic testing and genetic information. It proposes a framework that facilitates a critical analysis of the ethical, legal, and social issues of genetic testing. The ethical effects include privacy infringement, genetic discrimination, misleading advertisement, psychological impact, and individual autonomy. The legal impacts embrace consistent terminology, referral guidelines, patent wars, and new legislations. The social effects pertain to inequality, higher insurance fees, tax burden, and fear of new eugenics. Information and communication technologies dramatically augment the effect of genetic testing on these outcomes. This chapter argues that information and communication technologies and rapid advances in genetics challenge the existing legislation systems in North America. Therefore, policy-makers need to address the tension between the potential benefits and harms of genetic testing and genetic information.

Draping education to promote patient dignity: canadian physiotherapy student and instructor perceptions

PURPOSE

To determine the perceptions of educators and students in Canadian entry-level professional physiotherapy programmes with respect to the current draping curriculum and the methods of delivery of that content and to determine if there is a need for additional draping education time and resources in these programmes.

METHODS

Canadian university physiotherapy students (n=127) and educators (n=183) completed questionnaires designed by the authors. Data were collected via Survey Monkey, exported as Excel files, and analyzed using descriptive statistics and Pearson chi-square analysis.

RESULTS

Students and educators agreed that dignity as a concept and draping as a skill to protect patient dignity are both important and should be included in Canadian physiotherapy curricula. Respondents also agreed that students often have difficulty with draping. Educators identified barriers to teaching draping while students identified components of an effective educational resource on draping.

CONCLUSIONS

To enhance the development of effective draping skills among entry-level physiotherapists, draping education should be included in Canadian physiotherapy curricula. An effective draping educational resource should be developed for educators and students.

Purpose: To determine the perceptions of educators and students in Canadian entry-level professional physiotherapy programmes with respect to the current draping curriculum and the methods of delivery of that content and to determine if there is a need for additional draping education time and resources in these programmes. Methods: Canadian university physiotherapy students (n=127) and educators (n=183) completed questionnaires designed by the authors. Data were collected via Survey Monkey, exported as Excel files, and analyzed using descriptive statistics and Pearson chi-square analysis. Results: Students and educators agreed that dignity as a concept and draping as a skill to protect patient dignity are both important and should be included in Canadian physiotherapy curricula. Respondents also agreed that students often have difficulty with draping. Educators identified barriers to teaching draping while students identified components of an effective educational resource on draping. Conclusions: To enhance the development of effective draping skills among entry-level physiotherapists, draping education should be included in Canadian physiotherapy curricula. An effective draping educational resource should be developed for educators and students.

Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study

Background

To evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting.

Methods

A pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression.

Results

Structured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of “personal information overheard by others”, being “seen by irrelevant persons”, having “unintentionally heard inappropriate conversations from healthcare providers”, and experiencing “providers’ respect for my privacy”. There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis.

Conclusions

Significant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction.

Patients' perception and actual practice of informed consent, privacy and confidentiality in general medical outpatient departments of two tertiary care hospitals of Lahore

BACKGROUND

The principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which doctors in Lahore adhere to these principles during outpatient consultations.

MATERIAL & METHOD

The study was conducted at medical out-patient departments (OPDs) of two tertiary care hospitals (one public and one private hospital) of Lahore, selected using multi-stage sampling. 93 patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was observed through client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made by our data collectors.

RESULTS

Some degree of informed consent was obtained from only 9.7% patients in the public hospital and 47.8% in the private hospital. 81.4% of patients in the public hospital and 88.4% in the private hospital were accorded at least some degree of privacy. Complete informational confidentiality was maintained only in 10.8% and 35.5% of cases in public & private hospitals respectively. Informed consent and confidentiality were better practiced in the private compared to the public hospital (two-sample t-test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of our trained data collectors.

CONCLUSION

Observance of medical ethics is inadequate in hospitals of Lahore. Doctors should be imparted formal training in medical ethics and national legislation on medical ethics is needed. Patients should be made aware of their rights to medical ethics.