July 2007

Information Ethics in Paperless Hospitals

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While paperless hospitals are being introduced in Malaysia and all over the globe, there is  lack of a holistic code of ethics, specifically for handling massive computer-based information in these hospitals. Healthcare professionals such as medical practitioners and nurses in these paperless hospitals now need to have two codes of ethics to follow, namely, medical ethics and computer ethics. These medical professionals not only should handle patient's information; at the same time they also have to be proficient in handling computerized systems to ensure the security of the information. However, at the moment, there are no written guidelines, which can be followed by the healthcare professionals in Malaysian paperless hospitals.

The use of computers in today's business decisions has both revolutionized and benefited business. Yet, misuse of computers and unethical behaviour related to computer application systems have resulted in serious losses to business and society. Information technology (IT) provides organizations the opportunity to have almost instantaneous access to vast amounts of critical information about customers, competitors, employees, and suppliers. Unfortunately, recent incidents involving software piracy, computer viruses, data theft, system espionage and employee monitoring have emphasized the potential for unethical behaviour associated with the use of IT.

Medicine always aims to promote health, prevent and cure diseases. With the advancement of technology today, many innovative methods of cure are being introduced. However, several methods are rather controversial in nature i.e. assisted conception. Here medical ethics can play a role. Medical ethics is applied to keep track of what is right and what is wrong in  different areas of  healthcare.

Information Ethics in Healthcare in an e-age

There is a great need for some form of regulation concerning the collection, processing, storage and communication of medical data, ncluding images such as x-rays and eye scan. There must be strict control over this sensitive information. Patients' information can be used for any unethical purposes, such as insurance companies may use the information to ask the patients' family to buy their insurance, and irresponsible people may humiliate the patient among their neighbours, officemates, relatives and friends.

Patients have a right to expect that information systems are secure and will not in any way violate their privacy. Hence the method must ensure that the confidentiality of the medical data or information is always preserved, particularly when it involves the movement of information from one location to another, electronically.

It is ethically inappropriate to carry on providing the services if the system fails to safeguard the confidentiality of the patient information that is of a sensitive nature. Disclosure of these information is a betrayal of trust.

Therefore measures must be taken to ensure that unauthorized interception can be prevented. Even if the transmitted information is intercepted, it shouldn't be read. A comprehensive legal and ethical framework is necessary for the protection of the patients' rights. In Malaysia, Ministry of Health (MOH) has a code of conduct for medical officers and nurses.

This code of conduct guides them to be good practitioners, while performing their duty. It includes guidelines on behaviours of medical practitioners with patients, visitors, and also among themselves.

Even in other countries, hospitals  are focusing more on the patient's care, but only part of the code of ethics focuses on the patient's information handling. In fact, oaths and codes for medical practitioners vary from one country to another and even within countries, and they have many common features, including promises that physicians will consider the interests of their patients above their own, will not discriminate against patients on the basis of race, religion or other human rights grounds, will protect the confidentiality of patient information and will provide emergency care to anyone in need. But, sadly it still only focuses on the way they interact with patients directly, not through the computer system. Medical ethics in an ICT age is the need of the hour for every country, which has entered or about to enter the e-age.

Malaysian Paperless Hospital

The Malaysian Government is the major provider of healthcare for its people. Other important providers contributing to the health of the population in Malaysia include the private sector and non-government organizations (NGOs).

In the Seventh Malaysian Plan, it was stated that there will be 33 paperless public hospitals in Malaysia. There will be 8 hospitals using total hospital information system (THIS), while the other 25 smaller hospitals will use the hospital information system (HIS). But due to the economic crisis in 1998, those projects were put on hold, and were expected to be implemented during the Eighth Malaysian Plan.

However, until the early stage of the Ninth Malaysian Plan, only two hospitals are formally known as paperless hospitals, while implementation of other proposed hospitals are still on hold. Testing of the computerised systems have been given as reasons that contribute to this delay.

At the moment, these two hospitals do not have any code of ethics in handling patients' computer-based information system. All healthcare professionals (the physicians, the IT department staff and the record department staff) only practice their own department's policy or code of conduct. However, in order to make them understand more about the system they are using, it  might be better if there is one universal standard code, which can be read and practiced by all healthcare professionals across the country.

The Ambit and Role of Ethics

Here in this article, we focus on the information ethics in the paperless hospitals of Malaysia.  While paperless hospitals are being introduced in Malaysia and all over the globe, there is  lack of a holistic code of ethics, specifically for handling massive computer-based information in these hospitals. Healthcare professionals such as medical practitioners and nurses in these paperless hospitals now have two codes of ethics to follow, namely, medical ethics and computer ethics. These professionals not only handle patient's information; at the same time they also have to be proficient in handling computerized systems to ensure the security of the information. However, at the moment, there are no written guidelines, which can be followed by the healthcare professionals in Malaysian paperless hospitals. They are usually only given verbal guidelines on ethics in the early stages of their training. Lessons on the computerized systems are usually given by senior staff in the wards.

As stated before, currently, there are two fully operational paperless hospitals in Malaysia. These hospitals fully rely on computer information systems to improve their operations efficiency. Here  we describe the design of an ethical framework for healthcare professionals involved in handling computer-based information in these hospitals.

The design began with a draft framework of code of ethics for healthcare professionals, derived from a literature review on ethics related to them. The draft framework was incorporated in questionnaires, distributed randomly to healthcare professionals. The respondents were interviewed after completing the survey and many of their comments were directed to specific items in the survey. The research identified five major code of ethics, namely confidentiality, information protection, password management, computer usage and Internet usage. It is hoped that this ethical framework will guide healthcare professionals to act in an ethical manner, while using the medical information system in paperless hospitals. It is also important in their interactions with patients, colleagues and authorities, as well as in the conduct of medical research.

Ethics among hospitals' staff is important in order to make sure the success of these healthcare institutions and to  earn customers' trust. Research shows that there have been cases of healthcare professionals facing ethical dilemma while handling their patients' information. If these problems are not taken care of, the concerned hospitals  can receive a bad reputation.

However, here it deserves a mention that ethics is not about rules but about 'codes of conduct'. Ethics can be defined as the system of moral principles that have graduated to become standards for professional conduct. Ethics is about behaviour and about ways of thinking, especially in situations where our choice can affect the dignity and well being of others. Because ethical behaviour implies free choice, it cannot be captured or condensed in a rule. This involves  the challenge in its implementation. It is impossible to force adherence to an ethical standard: the notion of coercion itself is foreign to it. But individually we can make a promise to abide by them.

Methodology

Figure 1 shows how the research was being conducted. The research process consists of four phases. First, a comprehensive literature search was conducted to compile codes recommended by several organizations, as well as those suggested in various articles and publications. Then, those codes were compiled into a questionnaire form where respondents validated the codes by indicating whether it was accepted and can be applied in their working area. An exploratory study was conducted to ensure that the questionnaire was as clear as possible and would be able to measure what it was supposed to measure. Besides improving the questionnaire, the feedback and the data collected were used to provide some initial view of codes needed in the hospitals.

Second, hospitals using computer-based information system in handling their patients' information were identified. The finalized questionnaire was distributed to the healthcare professionals in those hospitals. The research uses a Multiple Perspective Method by Linstone (1993) to get multiple views of the codes from three 'lenses'-  technical view, organization view, and personal view of ethics. There is personal ethics, technical ethics and organization ethics in an organization. But, there is no code that can be used by these three groups. So, the research  combined all codes which can be practiced by these groups. Figure 2 (in page 36) will show the relationship between the ethics and the practitioners.

Final Code of Ethics Framework
                                                                
I.Confidentiality

A practitioner must

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