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Legal and Ethical Issues in Nursing Informatics

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Wondering how to send a HIPAA compliant email? According to HHS, "the Security Rule does not expressly prohibit the use of email for sending ePHI. However, the standards for access control, integrity and transmission security require covered entities to implement policies and procedures to restrict access to, protect the integrity of, and guard against unauthorized access to ePHI."

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Code of Medical Ethics Opinion 1.2.12

Innovation in technology, including information technology, is redefining how people perceive time and distance. It is reshaping how individuals interact with and relate to others, including when, where, and how patients and physicians engage with one another.

Telehealth and telemedicine span a continuum of technologies that offer new ways to deliver care. Yet as in any mode of care, patients need to be able to trust that physicians will place patient welfare above other interests, provide competent care, provide the information patients need to make well-considered decisions about care, respect patient privacy and confidentiality, and take steps to ensure continuity of care. Although physicians' fundamental ethical responsibilities do not change, the continuum of possible patient-physician interactions in telehealth/telemedicine give rise to differing levels of accountability for physicians.

All physicians who participate in telehealth/telemedicine have an ethical responsibility to uphold fundamental fiduciary obligations by disclosing any financial or other interests the physician has in the telehealth/telemedicine application or service and taking steps to manage or eliminate conflicts of interests. Whenever they provide health information, including health content for websites or mobile health applications, physicians must ensure that the information they provide or that is attributed to them is objective and accurate.

Similarly, all physicians who participate in telehealth/telemedicine must assure themselves that telemedicine services have appropriate protocols to prevent unauthorized access and to protect the security and integrity of patient information at the patient end of the electronic encounter, during transmission, and among all health care professionals and other personnel who participate in the telehealth/telemedicine service consistent with their individual roles.

Physicians who respond to individual health queries or provide personalized health advice electronically through a telehealth service in addition should:

(a) Inform users about the limitations of the relationship and services provided.

(b) Advise site users about how to arrange for needed care when follow-up care is indicated.

(c) Encourage users who have primary care physicians to inform their primary physicians about the online health consultation, even if in-person care is not immediately needed.

Physicians who provide clinical services through telehealth/telemedicine must uphold the standards of professionalism expected in in-person interactions, follow appropriate ethical guidelines of relevant specialty societies and adhere to applicable law governing the practice of telemedicine. In the context of telehealth/telemedicine they further should

(d) Be proficient in the use of the relevant technologies and comfortable interacting with patients and/or surrogates electronically.

(e) Recognize the limitations of the relevant technologies and take appropriate steps to overcome those limitations. Physicians must ensure that they have the information they need to make well-grounded clinical recommendations when they cannot personally conduct a physical examination, such as by having another health care professional at the patient's site conduct the exam or obtaining vital information through remote technologies.

(f) Be prudent in carrying out a diagnostic evaluation or prescribing medication by:

1. Establishing the patient's identity

2. Confirming that telehealth/telemedicine services are appropriate for that patient's individual situation and medical needs

3. Evaluating the indication, appropriateness and safety of any prescription in keeping with best practice guidelines and any formulary limitations that apply to the electronic interaction

4. Documenting the clinical evaluation and prescription

(g) When the physician would otherwise be expected to obtain informed consent, tailor the informed consent process to provide information patients (or their surrogates) need about the distinctive features of telehealth/telemedicine, in addition to information about medical issues and treatment options. Patients and surrogates should have a basic understanding of how telemedicine technologies will be used in care, the limitations of those technologies, the credentials of health care professionals involved, and what will be expected of patients for using these technologies.

(h) As in any patient-physician interaction, take steps to promote continuity of care, giving consideration to how information can be preserved and accessible for future episodes of care in keeping with patients' preferences (or the decisions of their surrogates) and how follow-up care can be provided when needed. Physicians should assure themselves how information will be conveyed to the patient's primary care physician when the patient has a primary care physician and to other physicians currently caring for the patient.

Collectively, through their professional organizations and health care institutions, physicians should:

(i) Support ongoing refinement of telehealth/telemedicine technologies, and the development and implementation of clinical and technical standards to ensure the safety and quality of care.

(j) Advocate for policies and initiatives to promote access to telehealth/telemedicine services for all patients who could benefit from receiving care electronically.

(k) Routinely monitor the telehealth/telemedicine landscape to:

1. Identify and address adverse consequences as technologies and activities evolve

2. Identify and encourage dissemination of both positive and negative outcomes

AMA Principles of Medical Ethics: I, IV, VI, IX

Read more opinions about this topic
Code of Medical Ethics: Patient-Physician Relationships
Visit the Ethics main page to access additional Opinions, the Principles of Medical Ethics and more information about the Code of Medical Ethics.

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Innovation in technology, including information technology, is redefining how people perceive time and distance. It is reshaping how individuals interact with and relate to others, including when, where, and how patients and physicians engage with one another. Telehealth and telemedicine span a continuum of technologies that offer new ways to deliver care.

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1. Have you or your hospital ever encountered a data breach? If so, what happened? What are some of the actions taken by your facility to prevent data breaches?

2. What are some of the legal and ethical concerns involving EMR documentation? Furthermore, what are some ways you and your facility strive to protect patient information?

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Legal and Ethical Implications of the EHR

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Enhanced Nurse Licensure Compact (eNLC) Implemented Jan. 19, 2018 | NCSBN

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The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing.

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Electronic medical records (EMRs) were pitched as a long-sought concept of computerized universal personal health material that would mitigate issues with access and barriers to care. In reality, when I speak of EMRs, I am referring to what they actually delivered to physicians, billing platforms that marginalize meaningful patient data necessary to inform diagnosis and therapeutic interventions.

If the promise lived up to an inkling of the reality, then the excessive clerical burden imposed on physicians to enter data, that often results in more eyes on the computer screen than the patient would not cause almost 1 in 5 U.S. physicians to plan to reduce their clinical hours in the coming year and nearly 1 in 50 to expect to leave the field entirely in the next 2 years to focus on a different career (see here).

Since the mandated rollout with financial penalties for noncompliance began, EMR companies selling multiple platforms without input from busy practitioners on the front lines have flourished (see here) at the expense of the doctor-patient relationship. Hospital and health systems have optimized and upgraded their reimbursement flows. A whole industry of coding and billing experts was created. Third party payers have added yet another layer between doctor and patient, entities rarely if ever considered.

So, now with "interoperability" being the du jour euphemism for fixing the ails of EMRs, it still appears that no one is asking questions of the real stakeholders here, the doctor and the patient. After all, any doctor could have identified these issues before EMRs were involuntarily thrust upon them.

Which brings me to my main concern of whether or not such forced implementation of EMRs, considered by some as coercive, violated the basic tenets of bioethics (see source here):
Principle of Respect for Autonomy
Patients and physicians were never asked about the use of electronic medical records, how they would be implemented and the ballooning access to protected health information they encourage. Patients were never fully instructed about the risks and benefits of the endless data EMRs collect that often is not used at all to make treatment decisions on their care. Nor were they consulted on the attention it diverts away from their doctor-patient interactions, time spent and the harm that can cause.
Principle of Justice
Penalizing those physicians in mid- or later career who did not grow up on technology or missed the window for it violates respect for many principles (e.g. the right to practice independent of a large institution and making the attempt cost prohibitive, ageism). It is unjust to do so as it directly contributed to early retirement or expeditious departure from medical practice. Often with EMRs a provider cannot go to the next page without answering certain questions that may or may not have anything to do with the patient's care. It is always the patient's right to decide what they wish to disclose. In addition, preoccupying their doctor with unnecessary extra steps can slow down a patient's getting relief from their suffering. This is not fair to individuals seeking or providing care. It worsens physician shortages, given the burdensome nature of EMRs doctors often cannot see as many patients.
Principle of Beneficence

Do as much good as you can which can reflect kind, compassionate care above and beyond the minimum, maintaining knowledge and skills, strive for the best interest of the patient etc.

EMRs often require protocols for completion per patient that have nothing to do with their individual care (e.g. inane prompts like assessing suicidal tendencies in a newborn or flu shot status in a trauma victim). They are cumbersome and can make accessing useful information a challenge. Transforming their physician into a data entry specialist by consuming their time erodes the doctor-patient relationship, chips away at things like bedside manner and effective communication that all can impede care. It keeps physicians in the office longer, performing extraneous, routinely redundant tasks on EMRs diminishing the time dedicated to high-quality care. Physicians went to medical school to take care of patients not unnecessarily divert their attention away from them. Since outpatient and inpatient locations as well as differing health centers can have disparate EMRs, given the vast number of companies sourcing them, excessive training and continued education are involuntarily required by staff to remain certified on their respective system. None of these mandatory sessions advance knowledge of disease management or help patients - instead they consume time that could be devoted to such useful skill acquisition or patient care.
Principle of Non-maleficence
EMRs do not speak between institutions which can cause delays in care since health professionals at one place cannot access the data from the other. EMRs routinely exacerbate the difficulty of getting the information. This can further infringe on a person's ability to choose their doctor given the undue pressure exerted upon them to remain within a hospital system for all of their care even if it is not in their best interest. For example, there could be a more experienced, knowledgeable doctor who is best suited to manage their particular condition at an outside facility.
To sum up
Given that all of these widely accepted (though sometimes debated) principles need to be respected for a medical procedure to be considered ethical, I conclude the implementation of EMRs was a disaster that reverberates to this day. At their best, they added another layer between physician and patient further eroding the relationship and at their worst, they were borderline negligent contributing to a premature exodus of seasoned professionals who had more to give patients and those who came after them professionally.

Under the guise of improving care, they have served as a money grab for competing profit centers at the expense of physicians and patients. With such a recent public focus on Facebook's misleading policies over use of our data, it will be interesting to see what happens when the spotlight shifts to our protected health information that is currently flying under the radar.

By Jamie Wells, M.D.

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Electronic medical records (EMRs) were pitched as a long-sought concept of computerized universal personal health material that would mitigate issues with access and barriers to care. In reality, when I speak of EMRs, I am referring to what they actually delivered to physicians, billing platforms that marginalize meaningful patient data necessary to inform diagnosis and therapeutic interventions.

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Electronic Health Records: Privacy And Security

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Case Studies: Healthcare Data Breach Risks