Reid Cushman, PhD University of Miami Ethics Programs UM-Miller School of Medicine

Ethics, Health Information Technology, and Primary Care

Baptist Health South Florida11th Annual Primary Focus Symposium

Reid Cushman, PhDUniversity of Miami Ethics Programs

UM-Miller School of MedicineDepartments of Medicine and Health Informatics

[email protected]

Objectives

• Describe how basic principles of biomedical ethics are applied to deployments of health information technologies.

• Identify and discuss the particular challenges and opportunities of advanced information technologies in primary care settings.

What does “moral philosophy” offer that’s relevant for decisions about today’s information technologies?

Rubens, “The Four Philosophers” c. 1611 (source: Wikimedia)ENIAC cycling units c. 1946 (source: Penn Library Exhibitions)IBM Watson supercomputer c. 2011 (source: Wikimedia)

Fair Information Practice Principles

1.Notice/Awareness2.Choice/Consent3.Access/Participation4.Integrity/Security5.Enforcement/Redress

a) Self-Regulationb) Private Remediesc) Government Enforcement

Source: Federal Trade Commission

HIPAA Privacy/Security “Rights”

1.Notice of Privacy Practices2.Access to and Copying of Records3.Correction/Amendment of Errors4.Accounting of Disclosures5.Additional Limits, Confidentiality6.Assurance of Reasonable and

Appropriate Security Practices7.Complaint and Investigation Process

Recent/upcoming HIPAA changes

1.“Breach” notifications2.Electronic access to records3.Expanded disclosure accounting4.Expanded restriction request rights5.More restrictions on resale, uses for

marketing, fundraising, research (?)6.Extension of requirements to BAs7.Audits (random)8.New penalty structure

November 8, 2011

“A feeble execution is but another phrase for a bad execution; and a government ill executed, whatever may be

its theory, must be, in practice, a bad government.” Alexander Hamilton, Federalist No. 70, 1788

How does all this translate into “challenges and opportunities” for deployments of information technologies in primary care settings?

Medical files c. 2012 (source: WBUR.org)Medical tablet computer c. 2012 (source: SUNY-Stony Brook) Bank vault door c. 2009 (source: Wikipedia.org)

Source: OECD Health Data 2011

0 1000 2000 3000 4000 5000 6000 7000 8000 900068

70

72

74

76

78

80

82

84

USACHL

KORNOR

ISRCHE

JPN

Heath sector expenditures per capita US $ PPP 2009

Life

expe

ctan

cy a

t birt

h (y

ears

)Life expectancy and health sector expenditures per capita

34 OECD countries, 2009

U.S. population profile: 1990, 2000, 2025, 2050, 2100

Source: U.S. Census Bureau, National Population Projection Pyramids (2011) 19902000202520502100

Source: CDC, Diabetes and Obesity, 2009 Age-Adjusted by County

Counties in top two quintiles for diabetes and obesityCounties in the bottom two quintiles for diabetes and obesityCounty-Level Estimates of Obesity (percentage)

Three levels of Prevention

Primaryprevention

Susceptible population

Reduced disease

incidence

Secondaryprevention

Asymptomatic population

Reduced prevalence / consequence

Tertiaryprevention

Symptomatic population

Reduced complications

/ disability

Source: adapted from B J Turnock, ch. 1, Public Health: What It Is and How it Works (5th ed., 2012)

Three levels of PreventionTertiar

y Prevention

/ Disease

Mgmt

Secondary Prevention /

Early Detection & Intervention

Primary Prevention / Well-Person Care

• Treatment and acute care• Chronic care• Complications management• Maintenance and rehabilitation

• Promotion of healthy behaviors and healthy environments

• Universal and targeted approaches to control of risk factors

• Screening• Case finding• Early intervention• Control risk co-factors – lifestyle

and medication

Image source: NIH

Tertiary prevention

Secondary prevention

Primary prevention

Bio-data-repository

Buying a system is only the beginning, and many ways the cheapest part. Successful implemen-tation requires changing practices.

“Despite strong evidence that clinical preventive services (CPS) reduce morbidity and mortality, CPS performance has not improved in adult primary care. In addition to implementing electronic health records (EHRs), key factors for improving CPS include providing actionable information at the point of care, technical support staff, and quality-improvement assistance. These resources are not typically available in small practices.”

Shih SC et al, “Health information systems in small practices. Improving the delivery of clinical preventive services” Am J Prev Med (2011 Dec,41(6))

“I, for one, welcome our new computer overlords.” Ken Jennings, Jeopardy, 16 January 2011

“I’m a doctor, not a counterinsurgent.” Emergency Holographic Doctor Stark Trek: Voyager, 1995-2001

“I’m a doctor, not a mechanic”Dr. ‘Bones’ McCoy

Star Trek (various), 1966-1989