M8/M9 Quiz

**CPOE (Computerized Provider Order Entry)

(CMS, 2010) Use of computer assistance to directly enter orders Order is documented/captured in a digital, structured, and computable format

***purpose, attributes, functions, and current use of CPOE in healthcare, as well as the major value and common barriers to CPOE adoption

-CPOE, face-to-face contact among team members diminished. -barrier was duplicate orders -took too long to download -too many clicks

Systematic discrimination (3 factors when combined that can make a difference)

Combination of factors can turn a difference in health into a social inequity in health The difference is: 1)systematic 2)socially produced & so modifiable 3)unfair ongoing debate on how to address.

CPOE (computerized PRACTIONER ORDER ENTRY) HIMS

Computerized practitioner order entry (HIMSS, 2010) Order entry application Assists practitioners with the creation and management of orders for services and medications

****Meaningful Use (current)

Providers show they're using certified EHR technology (CEHRT) in ways that can be measured significantly in quality and in quantity.

Prima facie Duties

At first view," or self-evident that Each ethical principle is binding unless it conflicts with another principle When the principles conflict, a person must decide which one to act on The theory of the 4 principles does not give guidance about which one to choose or how to prioritize them example only enough medicine for one patient, but two patients need to be treated, and half the medicine would do no good for either patient. This situation represents an ethical conflict between the duties of beneficence, nonmaleficence, and justice..

**Obligation (one way an ethical issue is divided into)

Minimum standard necessary to meet professional obligation examples: Provide competent medical care to individual patients Make sure patients understand the risks and benefits of treatment (meeting is professionalism ethical obligations EXCEED legal duties, some cases law mandates unethical conduct ethical responsibilities should supersede legal obligations.)

Equity w/HIT

Data capture Can monitor by population characteristics. Can uncover health care disparities. Tailor to patient needs Can enable competency-based patient education. Can tailor information to educational background and development status. Multi-modal functionality Can provide various ways for patients to get health information. Can decrease health care disparity. Decision support Can provide drug cost information. Can assist providers in selecting alternatives for low-income patients. ex: diabetes registry

sources of ethical standards are who?

Professional Organizations -American Medical Informatics Association, the International Medical Informatics Association, American Nursing Informatics Association, and the American Nursing Association. Other allied health care professionals may also have codes of ethics. Federal Agencies -Office of the National Coordinator for Health Information Technology, Laws -HIPAA -HITECH -State medical practice laws -False Claims Act -Occupational Safety & health Act -Clean Air Act Solid Waste Disposal Act

*****Accountable Care Organization

Provider reimbursements are tied to quality metrics and reductions in the total cost of care for assigned population of patients. from fee-for-service to more value-based care providers and suppliers (e.g., hospitals, physicians, and others involved in patient care) work together to coordinate Medicare covered services. private payers have also set up ACO-type plans. legal entities at the state level and are therefore bound by state law. Goal: Medicare beneficiaries receive lower cost, higher quality, and better coordinated care. the provider groups establish a mechanism for shared governance, and strive to provide high-quality and coordinated care. Patient-centered care decisions are joint between patient and providers. Under the proposed rule: Medicare would continue to cover Medicare services. Benchmarks developed by CMS for each ACO. ACO performance measured to determine if they receive shared savings, or held accountable for losses/poor performance. The Centers for Medicare and Medicaid Services (CMS), the entity that administers Medicare, will enter into three-year agreements with an ACO, and the ACO then assumes responsibility for the coordination, cost, quality, and overall care for assigned Medicare beneficiaries . Any cost savings are to be shared across the ACO partners. Care decisions are shared between the providers and the patient in an ACO — thereby, in addition to improving quality and increasing cost efficiency, an ACO would also contribute to a patient-centered orientation to care.

****Patient-Centered Medical Home- (current)

Providers organize care around patients, working in teams, coordinating care, and tracking over time. "an approach to providing comprehensive primary care for children, youth and adults. The PCMH is a healthcare setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient's family" (Patient-Centered Primary Care Collaborative). (PCPCC- a group of consumer groups, hospitals, providers, large employer groups, and many others, joined together to focus on the Patient-Centered Medical Home (PCMH))

Conscientious objection (pt autonomy is lost)

Refers to a situation in which a health care professional has a moral or religious objection to providing a particular medical intervention. example: Abortions Sterilization -Vasectomy Pain medications for terminally ill patients Emergency contraception

efficiency w/HIT

Wireless mobile technology Can capture vital signs. Can eliminate need to write or type vital signs. System integration Can pull forward historical information. Can reduce data collection time. Character expansion Can translate a few characters into phrases, sentences, or paragraphs. Can decrease typing time. example, the provider can type a few letters, such as WNL, which can be converted to within normal limits or an entire paragraph describing the normal assessment parameters Clinical decision support Can prompt for duplicate labs. Can reduce redundant laboratory testing. electronic picture archiving and communication system (PACS) for requesting radiological examinations and displaying images can improve efficiency and timelines

Hidden Curriculum define, how it's learned, and who's idea was this?

ideas of sociology professor Frederic Hafferty, medical students acquire their ethical standards in a variety of ways -Institutional policies (learn about values) "Reading between the lines" of written institutional policies -Statements about how much federal grant money the faculty is generating (tell students that attracting money to the institution is an important value) Noticing the language an institution uses -Evaluation activities Observing standards used for evaluation of success -The attributes and behaviors of those who are promoted may be more influential than ethics statements more powerful indicators of institutional values than ethics policies or ethics classes. -Following the money (promotions) example, brochures feature statements about how much grant money its faculty members generate, (this tells students that attracting money to the institution is an important internal value.).

Examples of exceptions to informed consent requirement

lacks mental capacity Adult w/severe developmental disability Severe dementia Children lack legal capacity Implied or presumed consent in an Emergency: Patient is unconscious OR lacks capacity ANND No surrogate decision-maker is available

ex: surgeon performed an operation for which he or she was not properly trained, ex: physician did not fully inform a patient about the risks of a treatment examples of what interacting?

malpractice law and ethics #2 in malpractice "standards of care were not met"

National Quality Strategy (NQS) aims. (BHA)

mandated by ACA: consistent with and supportive of Health and Human Services (HHS) delivery system reform initiatives Better care: improve overall quality by making health care more patient centered, reliable, accessible, and safe. Healthy people/healthy communities: improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher quality care. Affordable care: reduce the cost of quality health care for individuals, families, employers, and government. in order to do this; prioritizes 6 things: 1)Patient safety 2)Person-centered care: 3) coordination: 4)Effective treatment: . 5)Healthy living: 6)affordability

**Professionalism (an ethical standard)

means that a person acts in a way that meets the standards of his or her profession: Training and skills Ethical principles Behavior in accordance w/ generally accepted ideas of appropriate conduct within a specific profession component is to maintain the skills necessary to perform all work-related duties, such as taking continuing education classes. requires that people in the health care industry act in accord with certain standards standards of ___are not always clear. State medical practice laws are a primary source of legal standards of _____but other state and federal laws also apply. IN health informatics, it includes: -Knowledge of ethical requirements and ideals -Maintenance of professional skills

***"Concern for the scope of their action"

means that when health care professionals are confronted with these kinds of difficult questions, they are obligated to think about them. Who are health care professionals responsible to? Everyone in their community? Everyone in the country? How far does respect for autonomy go? Do animals have rights? Does the environment have rights?

**Ethics

is the study of what people think is right and wrong how people go about making those kinds of decisions Hippocratic Oath Codes of Ethics: American Medical Association American Nursing Association International Council of Nurses American Health Information Management Association American Medical Informatics Association

Bioethics ( 1 new academic field that address ethical issues in medicine)

the study of the ethical and moral implications of medical advances, research, and practice at the intersection of the law and the human rights of the patient. Example: genetic engineering and drug research.

Cons of advanced directives

undertreatment limit care inappropriately, leading to denying a patient potentially beneficial treatment. motivated by fear give unrealistic instructions may underestimate their ability to handle pain or disability, or they may underestimate what their own will to live would be waste providers' time ex: health care professionals may need to spend time finding the person who is designated to make decisions.

**Misuse

use (something) in the wrong way or for the wrong purpose.

artifacts

-Manmade tools that aid or enhance the worker's thinking abilities. -Developed to meet the demands of an activity Examples: Bedside references. so that the nurse can refer to them during the course of care Patient locator boards. list names of patients and room assignments so that unit personnel can track where patients are housed Report sheets. for hand-off purposes Documenting on paper then transcribing into electronic record. aid for the provider to remember data that he or she wants to enter into the electronic record at a later time.

duties for HCP

-informatics services necessary for health care professionals to carry out their obligations -"timely and secure access to relevant electronic records" -usability, integrity, and highest possible technical quality of the records"

The Code of Ethics of the International Medical Informatics Association lists nine general duties that informatics professionals owe to their employers. (CDLI)

1) Competence, (doesnt lie on trainging) diligence, Integrity (fairness) loyalty (The honest) & 8 others.

4 Basics Elements of Malpractice

1) Health care provider had a duty to the patient 2) standards of care were not met ex: surgeon performed an operation for which he or she was not properly trained, ex: physician did not fully inform a patient about the risks of a treatment closely intertwined with standards of professionalism. 3) failure to meet standards of care caused an injury 4) injury resulted in damages (harm) malpractice law and ethics interact.

HEALTHCARE SHOULD BE 6 aims of quality improvement state that health care should be: what? (TEPEES) And who said this?

1) Timely 2) Efficient 3) Patient-Centered 4) Effective 5) Equitable 6) SAFE U.S. Institute of Medicine (also referred to as the IOM) AKA National Academy of Medicine (NAM)

Where do we find guidance for the 4 duties of ethical medical standards?

1) codes of ethics, 2)statements of professional standards, & 3)consultations with colleagues, 4)ethics committees, and 5) ethics experts.

National Quality Strategy (NQS) Priorities

1)Patient safety: making care safer by reducing harm caused in the delivery of care. 2)Person-centered care: ensuring that each person and family is engaged as partners in their care. 3) Care coordination: promoting effective communication and coordination of care. 4)Effective treatment: promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. 5)Healthy living: working with communities to promote wide use of best practices to enable healthy living. 6)Care affordability: making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care

****Quality Improvement process

ongoing process that includes the setting of an aim and a progressive measurement, change test, and understanding of the system. continuous cycle of measurement, change, and learning starts. -Starts w/Aim of a clear idea (SMART GOAL) -must have MEASUREMENT (timeline) -CHANGE -Ability to learn & better understand the system we are changing To achieve long-lasting change, we need to move away from the project mentality and dive into the system we are trying to change. *needs improvement in U.S

****Informed Consent define, and patient must what?

patient knows, understands, and accepts the risks and benefits of treatment. (respect for autonomy) Patients must: Be capable of making medical decisions Be provided with all relevant information Understand the information given Communicate a decision Make voluntary decisions Lack of informed consent is often the basis for a malpractice case.

The Code of Ethics of the American Medical Informatics Association says

patients have the right to know about the existence of electronic records containing their personal medical data. says informatics professionals should not mislead patients about how these data are used. should truthfully answer all patient questions about their rights to review and revise their own medical data. should be helpful when a patient wishes to exercise those rights. should ensure that medical data are maintained in a secure, reliable, manner. medical data should never be used for purposes "outside the stated purposes, goals, or intents of the organization responsible for these data." treated with equal care, respect, and fairness. one of the eleven ethical principles is the obligation to accurately represent one's credentials. "Except in emergencies, health informatics professionals should only provide services in their areas of competence; however, they should always be honest and forthright about their education, experience or training."

Agency for Healthcare Research and Quality's (AHRQ) works w/US DHHHS produced the National Healthcare Quality Report (NHQR)

summarizes health care quality and access among various racial, ethnic, and income groups and other priority populations, such as residents of rural areas and people with disabilities." Many disparities are not decreasing; those that warrant increased attention include: care for cancer , heart failure, and pneumonia. Quality is improving, but pace is slow, especially in preventive care & chronic disease management. Quality Needs to be improved, especially for the uninsured.

***Respect for autonomy (Core principle of medical ethics)

that health care professionals must recognize that patients have the right to make their own treatment decisions based on their individual preferences and beliefs. HCP must not put excessive pressure on patients to make a particular choice or submit to treatments. Foundation of "informed consent" (ethical basis) -patient knows, understands, and accepts the risks and benefits of treatment. This concept is discussed in more detail in a later lecture & Medical confidentiality both a legal and an ethical duty. (Advanced directive )

Distributive Justice (ethic/core principle)

the idea that if resources are scarce, they will be allocated in a fair manner. How distributive justice should be implemented is controversial in our society,

***overuse

the potential for harm from the provision of a service that exceeds the possible benefit the depletion of a common resource that occurs when individuals ignore the fact that their use depletes the amount of the resource remaining for others

*Workarounds

unplanned responses to risks that were previously unidentified or accepted -Alternative processes that help workers avoid demands placed on them that they perceive to be unrealistic or harmful. -Unanticipated behaviors directly or indirectly caused by the EHR when the system impedes one's work. Examples: Nurses taking verbal orders rather than prescribers entering the order into CPOE due to workflow timing of event. Significant events located in multiple locations in the EHR due to lack of standardization of data entry screens. or like Data entered into multiple information systems due to lack of interfaces, resulting in transcription error. Drug orders written in a free-text message screen, causing delay or omission of medications because they are not seen by the pharmacist. Entering admission and discharges into the system in order to create lab test requisitions. Frequent reviews of the electronic health record every 15 minutes to detect new orders.

**underuse

failure to provide a service that would have produced a favorable outcome for the patient failure to provide appropriate or necessary services, or provision of an inadequate quantity or lower level of service than that required

Contemporary Topics in Medical Ethics

1-Informed consent 2-End-of-life issues 3-Conflicts of interest 4-Health care disparities 5-Conscientious objection

Profession

An occupation that Requires special knowledge and training Has standards for behavior that must be met

Beneficence and Nonmaleficence

What 2 Principles Requires that treatments be designed to maximize benefits and minimize risks ?

Federation of State Medical Boards

written a model state medical practice law. However, the states are not required to follow it, so the laws governing medical practice vary from state to state.

American Health Information Management Association (AHIMA) definition of Privacy

"A health information management professional shall: advocate, uphold, and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information" They place privacy in the number-one position on their lists of guiding ethical principles for health informatics professionals.

****Justice (Core principle of medical ethics)

"All persons are equal as persons and have a right to be treated accordingly" The risks of medical research should not fall disproportionally on one group of people medical ethics setting: -fairness -concepts that: All people have right to be treated equally If there is not enough to go around, what is available should be distributed fairly: Distributive justice is the idea that if resources are scarce, they will be allocated in a fair manner.

***Beneficience (Core principle of medical ethics)

"All persons have a duty to advance the good of others where the nature of this good is in keeping with the fundamental and ethically defensible values of the affected party" means that all people have a duty to advance the good of others as long as the nature of that good is in keeping with ethically defensible values. - idea that actions of HCP should BENEFIT people: -Prevent problems that may occur -Treat problems that have occurred Widely accepted as an appropriate goal of health care Applied at individual level and population-wide level: ex: giving antibiotics to a patient with pneumonia applies the principle of _____at the individual level. Giving elderly patients the opportunity to be vaccinated against pneumonia applies the principle at a population level actions to address problems the patient is already experiencing. main purposes of health care

International Medical Informatics Association (IMIA) definition of Privacy

"All persons have a fundamental right to privacy, and hence to control over the collection, storage, access, use, communication, manipulation and disposition of data about themselves" They place privacy in the number-one position on their lists of guiding ethical principles for health informatics professionals.

Patient Self-Determination Act (PSDA)

A federal law that mandates that every individual has the right to make decisions regarding medical care, including the right to refuse treatment and the right-to-die

example of interaction

Failure to meet professional standards can create legal liability (malpractice case)

Solid Waste Disposal Act (federal law protection of whistleblower)

Improper disposal of solid waste

Ethical issues in health Informatics

Sources of ethical standards in health informatics Professionalism Representing credentials Privacy, confidentiality, and security Respect for patients and coworkers Responding to unethical practices

***Quality Health Care & said who>

"Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge." (IOM, 2001)

Role of HIT in Improvement Efforts: Patient Safety (9 EXAMPLES)

(CPOE) Computerized provider order entry. Can reduce errors in drug prescribing and dosing. by triggering alerts when doses exceed acceptable limits, for example. Medical device interface Automated vital sign capture. Can reduce errors in transcription. reduces the possibility of error on the part of the human who collects this information by eliminating the transcription step. Knowledge links Reference information links. Can reduce errors due to lack of knowledge. Monitoring Quality metric reporting. can identify opportunities for improvement. Can identify opportunities for improvement. e-MAR Computerized medication administration record. Can reduce errors in drug administration. displaying a record of drugs that have already been administered, and those that are scheduled to be administered. e-Allergy list Computerized allergy list. Can reduce errors in preventable adverse drug events. Reminders Prompts and flags. Can reduce errors in omission. by reminding providers of interventions that are scheduled, Structured notes Standardized observations. Can reduce errors related to failure to detect subtle changes in status. use standardized observations that can reduce errors related to failure to detect subtle changes in status.

Duties owed to patients for Health informatics professionals

*4 core ethical principles -nonmalegencie -benefecience -Justice -autonomy *patients have a right to know about the existence of electronic records and how they will be used *Ensure that patient data is maintained in a safe, reliable manner *Never use patients' data for outside purposes *Respect data of all patients w/equal respect *The Code of Ethics of the American Medical Informatics Association: -right to know existence of electronic records containing their personal medical data -should not mislead about how data is used -be honest about rights to review & helpful when asked to exercise rights *ensure that medical data are maintained in a secure, reliable, manner. *the data of all patients should be treated with equal care, respect, and fairness.

**Privacy (#1 AMIA) & Security & confidentiality in HIT settings (1 of 4 duties in heath informatics )

*confidentiality-Do not improperly disclose information (part of professionalism, part of medical ethics, an ethical issue) & sSecurity-Safeguard patient information from improper access by others professional will take appropriate measures to protect the information from being inappropriately accessed by others. "respect for privacy" means-health informatics professionals must keep patients' information both confidential and secure. Includes: -Advocating for laws respecting patient privacy -Promoting these values among colleagues [Health Insurance Portability and Accountability Act (HIPAA) --> The law known as the Health Information Technology for Economic and Clinical Health Act, or HITECH says privacy & security rules] -remember law may overlap, exceed, or even conflict with ethical duties. A duty owed to EMPLOYER all requirements and standards regarding security are met.

10 Core Medical Professionalism (CHPR QAFS MR)

1)Professional competence doctors must keep up w/ discoveries in their field and keep their skills at the level needed to deliver appropriate care. The medical profession must monitor its members and provide ways for doctors to meet this goal. 2)Honesty with patients -principle includes the duty of informed consent. - requires doctors to be honest when medical errors occur. 3)Patient confidentiality 4)Appropriate relations with patients Because patients are often vulnerable and dependent on their health care providers, "physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose." 5)Improving quality of care 6)Improving access to care Doctors should work to reduce barriers and achieve a fair health care system. 7)Fair distribution of limited resources principle requires doctors provide cost-effective health care and avoid unnecessary tests and procedures. 8)Scientific knowledge Doctors have a duty to "uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use." 9)Managing conflicts of interest Doctors should not "compromise their professional responsibilities by pursuing private gain or personal advantage." An example is that doctors should report any relationships they have with pharmaceutical companies when they are conducting research or reporting the results of their research in journal articles. 10)Maintaining professional responsibilities Medical professionals should work together to get the most out of patient care, treat each other respectfully, and take part in the regulation of the profession.

4 Ethical Duties of Health Informatics professionals (PRRR)

1-duty to represent credentials accurately; 2-duty to protect patient privacy, & related ideas of confidentiality and security 3-duty to respect patients and coworkers; 4-duty to respond to unethical practices by others.

False Claims Act (federal law protection of whistleblower)

A false claim for payment has been made, such as Medicare fraud citizens who have evidence of fraud against federal government contracts and programs can sue, on behalf of the government, in order to recover the stolen funds. (whistleblower) examples: health care fraud are falsified claims for Medicare and Medicaid reimbursement. 2011 there was alot

health care profressional

A person who, by training and experience, has the knowledge to provide some aspect of health care delivery

Who made the 7 principles of PCMH?

American Academy of Family Physicians (AAFP). American Academy of Pediatrics (AAP). American College of Physicians (ACP). American Osteopathic Association (AOA).

duties owed to employers

Best data security measures "Highest possible qualitative standards of data collection, storage, retrieval, processing, accessing, communication, and utilization" "Appropriate systems for evaluating the technical, legal, and ethical acceptability of the data" The Code of Ethics of the International Medical Informatics Association lists nine general duties that informatics professionals owe to their employers. Competence, diligence (careful and persistent work or effort) Integrity loyalty & others) highest possible standards, all requirements and standards regarding security are met. systems for reviewing their processes and practices to make sure they are current and effective.

examples of conflict

Example: Court orders disclosure of patient information even though a physician has an ethical duty to maintain patient confidentiality, a court may order the release of a patient's medical records for use in a lawsuit.

***Ethics Committee

Group of people who meet to discuss ethical dilemmas accredited hospitals must have a process for resolving ethical questions Membership is usually diverse and may include: Doctors and nurses Other health care professionals Social workers and lawyers Religious professionals Members of the community Members of clergy consult with others In the United States, Many long-term-care facilities and home health care organizations also have ethics committees. discuss overlap-State and federal laws set standards for the practice of medicine /interactions-Failure to meet professional standards can create legal liability (malpractice case) of legal standards

Hippocratic Oath

Historical foundation of medical ethics States a moral obligation to maximize benefits of treatment and minimize harms of treatment Much of the original oath is not relevant today Modernized versions of the oath are used at some, but not all, medical schools reflect the beliefs of ancient Greek culture and are no longer relevant. Some, but not all, medical schools have new doctors take a modernized version of the oath.

****Goals of meaningful Use in EHR

Improve quality, safety, and efficiency. Engage patients and their families. Improve care coordination. Improve population and public health; reduce disparities. Ensure privacy and security protections. To qualify for federal incentives or avoid penalties, users of certified EHRs must demonstrate that they meet these criteria. 3 stages 1-Data capture & sharing priority of improving quality, safety, efficiency, and equity of health care 2-advance clinical processes must be able to demonstrate that they use that information to track key clinical conditions for quality improvement purposes. 3-improved outcomes meaningful use criteria were targeted at improving outcomes. providers and hospitals must be able to communicate that information to other care providers to ensure coordination of care. they need to lay foundation for reporting clinical quality measures and public health information. into 2 sets of criteria: a core set that must be met by all eligible providers, hospitals, and critical access hospitals in order to qualify for incentives, and a menu of additional criteria from which they must select any five choices to receive incentives.

***ways that HIT can HELP quality improvement, specifically unintended consequences and workarounds

Improve safety, effectiveness, efficiency, equity, timeliness, and patient-centeredness of care. Work to accomplish the best care for the whole population at the lowest cost.

Patient Centeredness w/HIT

Knowledge access Can provide patient-friendly websites. Can provide medical information and access to support groups. Tailor to patient needs Can enable clinical decision support. Can tailor information according to patient characteristics and condition. Patient Portal (WEB BASED PORTAL) Can allow patients to access and manage own health record. Can enable self-management. Disease management Can provide customized health education and disease management messaging. Can enable self-management

In health informatics professionalism includes (MK)

Knowledge of ethical requirements and ideals Maintenance of professional skills example: become familiar with the ideas expressed in the ethical codes written by health informatics organizations.

Distributive Justice (ethics principle)

is the idea that if resources are scarce, they will be allocated in a fair manner. How distributive justice should be implemented is controversial in our society,

Clean Air Act (federal law protection of whistleblower)

Practices that contribute to air pollution

Occupational Safety and Health Act (federal law protection of whistleblower)

Practices that result in an unsafe workplace

Advanced Directive Pro's

Preserves patient autonomy Prevents waste of resources Helps family know patient's wishes

Telemedicine

Remote consultation by patients with physicians or other health professionals via telephone, closed-circuit television, or the Internet. is the use of telecommunication technology to provide, enhance, or expedite health care services. Can provide Internet-based access. Can provide immediate access to medical information. This technology is typically used to increase access to clinical expertise to improve the effectiveness of care.

***4 Core/basic principles/DUTIES of Medical Ethics: (RBJN)

Respect for autonomy Beneficence Nonmaleficence Justice Does not give guidance on which to choose first. BUT can find guidance in codes of ethics, statements of professional standards, & consultations with colleagues, ethics committees, and ethics experts. Health care professionals must consider how broadly their ethical duties extend (" concern for scope of their action")

***Patient Safety

Safety is defined as freedom from the occurrence or risk of injury, danger, or loss. When applying the term to patients, we are speaking of protecting our patients from unintentional harm from the care that is intended to help them. HIT has the potential to protect patients from unintentional harm.

****Autonomy (a duty owed to patient)

Self-governance means people have the right to make their own decisions. without undue influence Health care decisions are voluntary All persons have a fundamental right to self-determination"

***Aspiration (one way an ethical issue is divided into)

Standard that one should strive to achieve but is not always attainable =in an ideal world but is not currently achievable in the real world. examples: Providing equal worldwide access to health care Find cures for currently incurable conditions

example of overlap

State and federal laws set standards for the practice of medicine

**Legal Standards

State medical practice laws are a primary source of _____standards of professionalism, but other state and federal laws also apply. ____ does not mean it's necessarily ethical. HCP must meet this and ethical standards

Timliness w/HIT

Telemedicine Can provide Internet-based access. Can provide immediate access to medical information. Time-sensitive prompts Can provide timed draw alerts. Can remind nurses when to draw blood based on a medication intervention. Task list schedules Clinicians reminders Can organize task list schedules. Can remind nurses when treatments are due. Patient reminders Can enable appointment scheduling. Can remind patients when they need to return for follow-up visits. electronic picture archiving and communication system (PACS) for requesting radiological examinations and displaying images can improve

***Non-maleficence (core principle of ethics)

The obligation to not intentionally create unnecessary harm or injury to the patient "All persons have a duty to prevent harm to other persons insofar as it lies within their power to do so without undue harm to themselves" Flipside: the principle that all people have a duty to prevent harm to others insofar as they can do so without undue harm to themselves. "First, do no harm." Applies to both commission and omission maleficent acts: Commission- aCt that causes harm Ex: performing needless surgery Ex: giving a patient a drug for the sole purpose of harming the person Omission- Failure to act (omit) when one should act Ex: intentionally withholding a helpful drug

***ways that HIT can HINDER quality improvement, specifically unintended consequences and workarounds

Unintended consequences of HIT: Lower quality and result in unsafe care. Can be minimized through best practices and avoidance of workarounds. Need to be studied further.

**Affordable Care Act

affordable care: reduce the cost of quality health care for individuals, families, employers, and government. Mandated by the Affordable Care Act, the National Quality Strategy (NQS) was developed through a transparent and collaborative process, with input from a range of stakeholders, to develop national consensus on priorities for quality measurement and improvement. More than 300 groups, organizations, and individuals, representing all sectors of the health care industry and the general public, provided comments. Based on this input, the NQS established a set of three overarching aims that build on the Institute for Healthcare Improvement's Triple Aim®. These aims are consistent with and supportive of Health and Human Services (HHS) delivery system reform initiatives to achieve better care, smarter spending, and healthier people through incentives, information, and the way care is delivered. The aims are used to guide and assess local, state, and national efforts to improve health and the quality of health care:

Adverse Event (AE)

any undesirable experience/INJURY associated with the use of a medical product in a patient

State medical practice laws

are a primary source of legal standards of professionalism, but other state and federal laws also apply. Defines the practice of medicine within the state Establishes a state medical board Governs/specifies testing and licensing of physicians Specifies/establishes procedures for investigation of complaints against MD's, enforcement, and discipline of physicians sets LEGAL standards of professionalism (but others apply) Federation of State Medical Boards-set a model of state medical practice law (States not required to follow) laws governing medicine practice vary from state to state.

examples of conflicts of interest (aspect of professionalism)

arises when a person is faced with a situation in which a primary interest conflicts with a secondary motivation. Primary duties include ethical and legal requirements, such as the obligation to keep patient information private. Secondary motivations are personal interests such as the opportunity for financial gain Example: Patients get medical appointments in order of listing in database. Close friend is far down, asks to be moved up Primary duty: Treat all patients fairly Secondary motivation: Friendship Any potential conflict of interest should be disclosed to appropriate parties. In this example, it might be appropriate to disclose to a supervisor that a friend requested preferential treatment and assure the supervisor that the proper protocol will be observed

Measurement

essential component of quality since you must have the ability to measure change to direct change in the appropriate direction 3 types: process-Are we doing what we must to get the improvement we seek? ex: clinical guidelines outcome-Are we getting what we expect? (measures determine the impact of our changes in the system. They measure results about a person's health and well-being.) balance-Are we causing new problems in other parts of the system? (tend to be measures of cost or patient experiences, any of the process or outcome measures could be used as balancing measures if they help us look at the whole system.)

only enough medicine for one patient, but two patients need to be treated, and half the medicine would do no good for either patient. what is the ethical conflict between???

ethical conflict between the duties of beneficence, nonmaleficence, and justice.

Setting professional standards through medical practice laws is one example of how what interacts? (EPL) self-regulation of the healthcare profession -HCP has ethical goals BUT severities of potential consequences can make difficult for profession to police itself

ethics, professionalism, and law

Health and human rights ( 1 new academic field that address ethical issues in medicine)

examines a vast array of ethical concerns around such issues as health care inequities, vulnerable populations, reproductive and sexual health, death and dying, and more.

***Quality Healthcare said by who? who defines it?

is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge." (IOM, 2001) HCP-applicatiion of EB principles Payers-Cost vs outcomes Professional and regulatory Bodies- conformity w/standards patients & families0- communication & timeliness

Secondary Interest & examples (conflicts of interest)

individual health care professional's personal motivations. Examples: Financial gain professional advancement Recognition achievement Favors to friends and family or to students and colleagues problem arises only when these personal goals have the potential to compromise decision-making about a primary interest, such as the best possible patient care. example of a potential conflict of interest is the practice of pharmaceutical companies giving gifts to physicians. Some researchers argue that even small gifts, such as pens and coffee mugs, can influence physicians to prescribe the company's drugs more often.

Conflict of Interest defined by Institute of Medicine (2009)

is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.

Enhancing clinical effectiveness w/HIT

providing knowledge links to clinical practice guidelines in order to increase use of best practices; quality measure reporting to identify gaps in practice; reminders in the form of practice alerts and flags; structured notes to guide providers through standardized observations to enhance assessment and diagnosis. *telemedicine* to increase access to clinical expertise to improve effectiveness of care

whistleblower

someone who reports illegal or unethical behavior to his or her superiors at work or to outside authorities. health care whistleblowing, - telling a patient about an error -disclosing violations of professional conduct that are occurring throughout institution. 6 /10 people who observe workplace misconduct will report it may be even lower in the health care professions. Fewer than 5% of medical students in their last weeks of training said they would report unethical behavior

Primary Interest & examples (Conflicts of interest)

such ideals as ethical obligations and professional duties. examples: welfare of patients integrity of medical research quality of medical education