Ethical issues and the electronic health record

Ethical and regulatory challenges of AI technologies in healthcare: A narrative review

Over the past decade, there has been a notable surge in AI-driven research, specifically geared toward enhancing crucial clinical processes and outcomes. The potential of AI-powered decision support systems to streamline clinical workflows, assist in diagnostics, and enable personalized treatment is increasingly evident. Nevertheless, the introduction of these cutting-edge solutions poses substantial challenges in clinical and care environments, necessitating a thorough exploration of ethical, legal, and regulatory considerations. A robust governance framework is imperative to foster the acceptance and successful implementation of AI in healthcare. This article delves deep into the critical ethical and regulatory concerns entangled with the deployment of AI systems in clinical practice. It not only provides a comprehensive overview of the role of AI technologies but also offers an insightful perspective on the ethical and regulatory challenges, making a pioneering contribution to the field. This research aims to address the current challenges in digital healthcare by presenting valuable recommendations for all stakeholders eager to advance the development and implementation of innovative AI systems.

Development of integrated electronic medical and dental record competencies and impact of training modalities

BACKGROUND

The American Recovery and Reinvestment Act provided incentives for the adoption of electronic health records. The integrated electronic medical and dental records (iEMDRs) can minimize healthcare charting errors. The use of iEMDR by healthcare students requires training and competence. There are no defined student competencies to assess the effective and responsible use of iEMDR in dentistry. The goal of this study was to propose a student competency model and study the impact of training modalities on iEMDR competency.

METHODS

This retrospective observational cohort study evaluated de-identified assessment scores (AS) and performance scores (PS) in predoctoral dental student (PDS) and advanced standing predoctoral (ASP) student cohorts that received remote or in-person iEMDR training. The AS and PS evaluated the knowledge and application of iEMDR, respectively. A voluntary survey evaluated students' self-perceived preparedness for iEMDR use. Linear regressions were used to determine the association between training modality and scores. Mantel-Haenszel ordinal chi-square tested differences between groups and agreement by training type. Statistical significance was set at 0.05.

RESULTS

The sample size (N = 214) provided 95% power to detect differences between study groups. The knowledge of iEMDR (AS) was not impacted due to the training type (p = 0.90) in either student cohorts, whereas the application of knowledge (PS) was higher in ASP student cohort after remote training (p < 0.001) as compared to PDS student cohort. Higher proportion of students perceived preparedness after remote learning in comparison to in-person training (p < 0.001).

DISCUSSION

The iEMDR competency model was useful to test the effective and responsible use of iEMDR, and remote training improved students' self-perceived preparedness.

Information Security Behavior in Health Information Systems: A Review of Research Trends and Antecedent Factors

This study aims to review the literature on antecedent factors of information security related to the protection of health information systems (HISs) in the healthcare organization. We classify those factors into organizational and individual aspects. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Academic articles were sourced from five online databases (Scopus, PubMed, IEEE, ScienceDirect, and SAGE) using keywords related to information security, behavior, and healthcare facilities. The search yielded 35 studies, in which the three most frequent individual factors were self-efficacy, perceived severity, and attitudes, while the three most frequent organizational factors were management support, cues to action, and organizational culture. Individual factors for patients and medical students are still understudied, as are the organizational factors of academic healthcare facilities. More individual factors have been found to significantly influence security behavior. Previous studies have been dominated by the security compliance behavior of clinical and non-clinical hospital staff. These research gaps highlight the theoretical implications of this study. This study provides insight for managers of healthcare facilities and governments to consider individual factors in establishing information security policies and programs for improving security behavior.

Digital Transformation in Ophthalmic Clinical Care During the COVID-19 Pandemic

ABSTRACT

COVID-19 has placed unprecedented pressure on health systems globally, whereas simultaneously stimulating unprecedented levels of transformation. Here, we review digital adoption that has taken place during the pandemic to drive improvements in ophthalmic clinical care, with a specific focus on out-of-hospital triage and services, clinical assessment, patient management, and use of electronic health records. We show that although there have been some successes, shortcomings in technology infrastructure prepandemic became only more apparent and consequential as COVID-19 progressed. Through our review, we emphasize the need for clinicians to better grasp and harness key technology trends such as telecommunications and artificial intelligence, so that they can effectively and safely shape clinical practice using these tools going forward.

Data privacy and confidentiality from the perspectives of general public and health care providers in Jordan

OBJECTIVES

To assess knowledge, attitude, and beliefs about the right to privacy and confidentiality from the viewpoints of the general public (GP) and the health system (HS) professionals in Jordan.

METHODS

An online-based cross-sectional descriptive questionnaire was distributed across Jordan during May & June of 2020. A total number of 388 respondents filled in the online survey assessing their knowledge, attitude, and opinion about the right to privacy and confidentiality being practiced during the professional contact between the patients and their health care providers.

RESULTS

Amongst the respondents, 44 (11.3%) participants were health care professionals, and 344 (88.6%) participants were from the general public. Most of the respondents were females (69.6%) and the mean age was about 27 years. The main sources of knowledge about patients' right to privacy and confidentiality regulations were from school and media platforms. Only 18.1% of the GP respondents reported that they have been introduced to patients' right to privacy and confidentiality regulations by medical staff during professional contact. Almost about 97% of GP respondents and 93.2% of HS professionals valued patients' right to assure the level of their data privacy prior to receiving medical care. A significantly (P = .012) higher percentage (93%) of GP respondents believed that there should be no prioritisation of privacy based on the gender of the patient. Most of the GP respondents had concerns about electronic medical records being violated and their data being reached by unauthorised parties.

CONCLUSION

The general public and health system professionals in Jordan are familiar with the patients' right to privacy and confidentiality regulations. More efforts must be put in place to inform patients about their rights to privacy and confidentiality practices when they are in professional contact with their healthcare providers. In addition, rules, laws, and legal agreements must be effectively established and monitored to prevent privacy violations.

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.

Preferences for Accessing Electronic Health Records for Research Purposes: Views of Parents Who Have a Child With a Known or Suspected Genetic Condition

OBJECTIVES

The purpose of this study was to examine parental preferences for researchers accessing their child's electronic health record across 3 groups: those with a child with (1) a known genetic condition (fragile X syndrome FXS), (2) a suspected genetic condition (autism spectrum disorder [ASD]), and (3) no known genetic condition (typically developing).

METHODS

After extensive formative work, a discrete choice experiment was designed consisting of 5 attributes, each with 2 or 3 levels, including (1) type of researcher, (2) the use of personally identifiable information, (3) the use of sensitive information, (4) personal importance of research, and (5) return of results. Stratified mixed logit and latent class conditional logit models were examined.

RESULTS

Parents of children with FXS or ASD had relatively higher preferences for research conducted by nonprofits than parents of typically developing children. Parents of children with ASD also preferred research using non-identifiable and nonsensitive information. Parents of children with FXS or ASD also had preferences for research that was personally important and returned either summary or individual results. Although a few child and family characteristics were related to preferences, they did not overall define the subgroups of parents.

CONCLUSIONS

Although electronic health record preference research has been conducted with the general public, this is the first study to examine the opinions of parents who have a child with a known or suspected genetic condition. These parents were open to studies using their child's electronic health record because they may have more to gain from this type of research.

The Relationship between the Nurses' Perception of Electronic Health Records and Patient Privacy

The aim of this study is to examine the relationship between the nurses' perception of electronic health records and patient privacy regarding patient information and socio-economic variables. The implementation part of the study was conducted on nurses working in a public hospital located in the Kilis province in Turkey. As a result of the analysis, the increase in the perceptions of the participants regarding the electronic health records statistically increases their perceptions about patient privacy. It was also determined that the scores of nurses regarding patient privacy showed statistically significant differences based only on the total working time in the current unit.

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.

Ethical, Legal, and Social Issues Related to the Inclusion of Individuals With Intellectual Disabilities in Electronic Health Record Research: Scoping Review

Background

Data from electronic health records (EHRs) are increasingly used in the field of genetic research to further precision medicine initiatives. However, many of these efforts exclude individuals with intellectual disabilities, which often stem from genetic conditions. To include this important subpopulation in EHR research, important ethical, legal, and social issues should be considered.

Objective

The goal of this study was to review prior research to better understand what ethical, legal, and social issues may need further investigation when considering the research use of EHRs for individuals with genetic conditions that may result in intellectual disability. This information will be valuable in developing methods and best practices for involving this group in research given they are considered a vulnerable population that may need special research protections.

Methods

We conducted a scoping review to examine issues related to the use of EHRs for research purposes and those more broadly associated with genetic research. The initial search yielded a total of 460 unique citations. We used an evaluative coding process to determine relevancy for inclusion.

Results

This approach resulted in 59 articles in the following areas: informed consent, privacy and security, return of results, and vulnerable populations. The review included several models of garnering informed consent in EHR or genetic research, including tiered or categorical, blanket or general, open, and opt-out models. Second, studies reported on patients’ concerns regarding the privacy and security of EHR or genetic data, such as who has access, type of data use in research, identifiability, and risks associated with privacy breach. The literature on return of research results using biospecimens examined the dissension in the field, particularly when sharing individualized genetic results. Finally, work involving vulnerable populations highlighted special considerations when conducting EHR or genetic research.

Conclusions

The results frame important questions for researchers to consider when designing EHR studies, which include individuals with intellectual disabilities, including appropriate safeguards and protections.

Patient Data Sharing and Confidentiality Practices of Researchers in Jordan

Purpose

The main focus of this study is to assess the knowledge and practices of healthcare practitioners regarding data sharing, security, and confidentiality, with a focus on the use of health data retrieved from electronic health records (EHRs) for research purposes.

Methods

A descriptive, cross-sectional, questionnaire-based survey study was conducted across all academic institutions including all researchers in the medical field in Jordan. Personal and administrative practices in data sharing were assessed through collecting data from respondents.

Results

The response rate was 22% with an average of 10.25 years of experience in publications. Almost 60% had published at least 1 to 3 studies using EHRs. The prevalence of researchers who "Always" used antivirus software and preserved patient's information was 75.5% and 92.2%, respectively. However, other personal security and confidentiality measures were not satisfactory. Less than half of health data used in the research was "Always" anonymised or encrypted and only around 44.0% had "Always" used sensitive data with more specificity than normal data.

Conclusion

Confidentiality and data sharing practices of healthcare practitioners and researchers were generally less than optimal. Efforts from healthcare providers, health institutions, and lawmakers should be put in place to protect the security and confidentiality of electronic patient data.

Satisfaction with Paper-Based Dental Records and Perception of Electronic Dental Records among Dental Professionals in Myanmar

Objectives

To overcome challenges in the implementation of electronic dental record systems in a low-resource setting, it is crucial to know the level of users’ satisfaction with the existing system of paper-based dental records and their perceptions of electronic dental records.

Methods

A cross-sectional paper-based questionnaire survey was conducted among Myanmar dental professionals who worked in one of two teaching hospitals or in private dental clinics. Descriptive data were analyzed and regression analysis was carried out to identify factors influencing perceptions of electronic dental records.

Results

Most dental professionals (>60%) were satisfied with just three out of six aspects of paper-based dental records (familiarity, flexibility, and portability). In addition, generalized positive perceptions were found among decision makers towards electronic dental records, and 86% of dentists indicated that they were willing to use them. Financial concerns were identified as the most important barrier to the implementation of electronic dental records among dentists who were not willing to use the proposed system.

Conclusions

The first step towards implementing electronic dental records in Myanmar should be improvement of the content and structure of paper-based dental records, especially in private dental clinics. Utilization of appropriate open-source electronic dental record software in private dental clinics is recommended to address perceived issues around financial barriers. For the long term, we recommend providing further education and training in health informatics to healthcare professionals to facilitate the efficient use of electronic dental record software in Myanmar in the future.

Examination of an Electronic Patient Record Display Method to Protect Patient Information Privacy

Electronic patient records facilitate the provision of safe, high-quality medical care. However, because personnel can view almost all stored information, this study designed a display method using a mosaic blur (pixelation) to temporarily conceal information patients do not want shared. This study developed an electronic patient records display method for patient information that balanced the patient's desire for personal information protection against the need for information sharing among medical personnel. First, medical personnel were interviewed about the degree of information required for both individual duties and team-based care. Subsequently, they tested a mock display method that partially concealed information using a mosaic blur, and they were interviewed about the effectiveness of the display method that ensures patient privacy. Participants better understood patients' demand for confidentiality, suggesting increased awareness of patients' privacy protection. However, participants also indicated that temporary concealment of certain information was problematic. Other issues included the inconvenience of removing the mosaic blur to obtain required information and risk of insufficient information for medical care. Despite several issues with using a display method that temporarily conceals information according to patient privacy needs, medical personnel could accept this display method if information essential to medical safety remains accessible.

Should medical students track former patients in the electronic health record? An emerging ethical conflict

Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.

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

Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was recently adopted by a team of informaticists who are designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in this process, especially when principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and nonmaleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper, we show how using ethical principles can help in the design of EHRs by first explaining how ethical principles can and should be used generally, and then by discussing how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest.

Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology

Evaluation and improvement of quality of care provided to the patients are of crucial importance in the daily clinical practice and in the health policy planning and financing. Different tools have been developed, including incident analysis, health technology assessment and clinical audit. The clinical audit consist of measuring a clinical outcome or a process, against well-defined standards set on the principles of evidence-based medicine in order to identify the changes needed to improve the quality of care. In particular, patients suffering from chronic renal diseases, present many problems that have been set as topics for clinical audit projects, such as hypertension, anaemia and mineral metabolism management. Although the results of these studies have been encouraging, demonstrating the effectiveness of audit, overall the present evidence is not clearly in favour of clinical audit. These findings call attention to the need to further studies to validate this methodology in different operating scenarios. This review examines the principle of clinical audit, focusing on experiences performed in nephrology settings.

Tissue banking, bioinformatics, and electronic medical records: the front-end requirements for personalized medicine

Personalized medicine promises patient-tailored treatments that enhance patient care and decrease overall treatment costs by focusing on genetics and "-omics" data obtained from patient biospecimens and records to guide therapy choices that generate good clinical outcomes. The approach relies on diagnostic and prognostic use of novel biomarkers discovered through combinations of tissue banking, bioinformatics, and electronic medical records (EMRs). The analytical power of bioinformatic platforms combined with patient clinical data from EMRs can reveal potential biomarkers and clinical phenotypes that allow researchers to develop experimental strategies using selected patient biospecimens stored in tissue banks. For cancer, high-quality biospecimens collected at diagnosis, first relapse, and various treatment stages provide crucial resources for study designs. To enlarge biospecimen collections, patient education regarding the value of specimen donation is vital. One approach for increasing consent is to offer publically available illustrations and game-like engagements demonstrating how wider sample availability facilitates development of novel therapies. The critical value of tissue bank samples, bioinformatics, and EMR in the early stages of the biomarker discovery process for personalized medicine is often overlooked. The data obtained also require cross-disciplinary collaborations to translate experimental results into clinical practice and diagnostic and prognostic use in personalized medicine.

The ethics of health information technology in oncology: emerging isssues from both local and global perspectives

Health information technology (HIT) is ever-increasing in complexity and has incrementally become a fundamental part of our everyday clinical lives. As HIT becomes more complex and commonplace, so do the questions it raises about stewardship and usage of data, along with the ethics of these applications. With the development of rapid-learning systems, such as ASCO's CancerLinQ, careful thought about the ethics and applications of these technologies is necessary. This article uses the principles-based framework of modern bioethics to examine evolving ethical issues that arise in the context of HIT and also discusses HIT's application in reducing cancer care disparities in the developing world. We recognize that this topic is quite broad, so here we provide an overview of the issues, rather than any definitive conclusions about a particular "correct path." Our hope is to stimulate discussion about this important topic, which will increasingly need to be addressed in the oncology community.

Ethics, Privacy, and the Future of Genetic Information in Healthcare Information Assurance and Security

The risks associated with the misuse and abuse of genetic information are high, as the exploitation of an individual’s genetic information represents the ultimate example of identity theft. Hence, as the frontline of defense, information assurance and security (IAS) practitioners must be intimately familiar with the multidimensional aspects surrounding the use of genetic information in healthcare. To achieve that aim, this chapter addresses the ethical, privacy, economic, and legal aspects of the future uses of genetic information in healthcare and discusses the impact of these uses on IAS. The reader gains an effective ethical framework in which to understand and evaluate the competing demands placed upon the IAS practitioners by the transformative utility of genomics.