Trustworthy shared electronic health records: recordkeeping requirements and HealthConnect

HealthConnect is a proposed national electronic health record system, centred on electronic health event summaries, that capture all health encounters of those patients and health care professionals who "opt in" to the system. This article reports on key findings of an analysis of HealthConnect's data principles, systems and business architecture, from a records continuum perspective, and from recordkeeping requirements of reliability and authenticity. It concludes that HealthConnect lacks critical recordkeeping functionality and that inadequate policy with regard to ownership, consent and privacy impacts on the business and systems architecture, and consequently its ability to deliver trustworthy records.     

HealthConnect and privacy: a policy conundrum

A shared electronic health record is intrinsically privacy-invasive because it creates a comprehensive record for information-sharing. The author explains the significance of information privacy and why it is that health information warrants special protection. She also provides an overview of the existing regulatory framework and an evaluation of suggested options and proposals for addressing privacy-related issues. Her analysis of suggested consent models suggests that they ultimately involve a trade-off between privacy and the broader benefits promised by HealthConnect and that obtaining the right balance is essential if HealthConnect is to achieve optimal health outcomes.     

HealthConnect and the duty of care: a dilemma for medical practitioners

This article asks whether medical practitioners' duty of care to their patients will encompass participation in the HealthConnect shared electronic records initiative. Medico-legal aspects of the HeathConnect scheme relating to the nature of shared electronic health record summaries (SEHRS) are examined, focusing on their function as an element of patient care and their ultimate purpose. The analysis is based on the premise that an incomplete and hence inaccurate shared electronic health record summary is clinically and legally more perilous than no record at all.     

Ethics, Information Technology, and Public Health: New Challenges for the Clinician-Patient Relationship

Increasingly widespread adoption of health information technology tools in clinical care increases interest in ethical and legal issues related to the use of these tools for public health and the effects of these uses on the clinician-patient relationship. It is argued that patients, clinicians, and society have generally uncontroversial duties to support civil society's public health mission, information technology supports this mission, and the effects of automated and computerized public health surveillance are likely to have little if any effect on the clinician-patient relationship. It is also suggested, nevertheless, that electronic public health surveillance raises interesting and important ethical issues, some of which can be addressed if not resolved by empirical research, especially regarding patient preferences about secondary use of health data and their moral obligation to contribute to population- based health.     

The Hippocratic Bargain and Health Information Technology

The shift to longitudinal, comprehensive electronic health records (EHRs) means that any health care provider (e.g., dentist, pharmacist, physical therapist) or third-party user of the EHR (e.g., employer, life insurer) will be able to access much health information of questionable clinical utility and possibly of great sensitivity. Genetic test results, reproductive health, mental health, substance abuse, and domestic violence are examples of sensitive information that many patients would not want routinely available. The likely policy response is to give patients the ability to segment information in their EHRs and to sequester certain types of sensitive information, thereby limiting routine access to the totality of a patient's health record. This article explores the likely effect on the physician-patient relationship of patient-directed sequestration of sensitive health information, including the ethical and legal consequences.     

Illusions of necessity: evading responsibility for choice in health care

Discretionary power is commonly defended by denial of its existence, the allegation of inevitability. Objective external conditions and forces are claimed to dictate policy decisions with tangible distributional effects. In health policy, such forces include the aging of the population, the extension of technology, and the demands of ethical standards. Taken together, these forces create relentless upward pressure on costs, to levels which society "cannot afford," necessitating sacrifice of the interests of the "less eligible." Yet quantitative analysis of these forces does not sustain the argument; in each case the source of cost escalation is not external pressure but the way in which the health care system itself reacts. Less costly and equally effective options are demonstrably available, but would threaten provider interests and broader ideologies. A spurious cloak of inevitability serves to promote and justify political choices.     

The Ethical Health Lawyer: An Empirical Assessment of Moral Decision Making

Writing in 1999, legal ethics scholar Brad Wendel noted that "[v]ery little empirical work has been done on the moral decision making of lawyers." Indeed, since the mid-1990s, few empirical studies have attempted to explore how attorneys deliberate about ethical dilemmas they encounter in their practice. Moreover, while past research has explored some of the ethical issues confronting lawyers practicing in certain specific areas of practice, no published data exists probing the moral mind of health care lawyers. As signaled by the creation of a regular column "devoted to ethical issues arising in the practice of health law" in the Journal of Law, Medicine & Ethics , the time to address the empirical gap in the professional ethics literature is now. Accordingly, this article presents data collected from 120 health care lawyers. Presenting this population with a number of hypothetical scenarios relating to how they would respond when confronting an ethical dilemma without an obvious solution or when facing a situation in which their personal values were in tension with their professional obligations, this article represents a first step toward better understanding how lawyers who practice in health care settings understand and resolve the moral discomfort they encounter in their professional lives.     

HIPAA administrative simplification: standard unique health identifier for health care providers. Final rule

This final rule establishes the standard for a unique health identifier for health care providers for use in the health care system and announces the adoption of the National Provider Identifier (NPI) as that standard. It also establishes the implementation specifications for obtaining and using the standard unique health identifier for health care providers. The implementation specifications set the requirements that must be met by "covered entities": Health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form in connection with a transaction for which the Secretary has adopted a standard (known as "covered health care providers"). Covered entities must use the identifier in connection with standard transactions. The use of the NPI will improve the Medicare and Medicaid programs, and other Federal health programs and private health programs, and the effectiveness and efficiency of the health care industry in general, by simplifying the administration of the health care system and enabling the efficient electronic transmission of certain health information. This final rule implements some of the requirements of the Administrative Simplification subtitle F of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).     

法学教育中的法律伦理教育问题研究

从法律的内在价值要求、我国法治建设中存在的问题,提出法律伦理教育是我国法学教育不可或缺的重要组成部分.法律伦理包括蕴含在法律制度中的制度伦理与法律职业者在职业活动中的法律行为伦理即职业道德两部分.法律伦理教育的目标就是要把学生培养成为具有健全的法律伦理人格,有助于法律终极目标实现的"社会医生".这一目标的实现有赖于法学教育理念的重构和法学教学方法的转变.目前,开展法律伦理教育面临的障碍主要有思想认识上的偏颇,社会"道德滑坡"的大环境以及法律国家主义的影响等.     

Can an employer-based health insurance system be just?

It is America's distinctive practice to tie private health insurance to employment, and recent proposals have tried to retain this link through mandating that all employers provide health insurance to their employees. My primary approach to these issues is neither economic, nor historical, nor political but ethical. After a brief historical overview, I outline a general approach to evaluating the ethical significance of linking the distributions of distinct goods. I examine whether an unjust distribution of jobs spoils justice in the distribution of health insurance, taking as a central example gender inequities in employment and exploring their impact on job-based health insurance. Second, I explore the possibility that justly awarding jobs guarantees justice in employment-sponsored insurance. However, linking the distributions of different goods remains problematic, because such links inevitably undermine equality by enabling the same individuals to enjoy advantages in many different distributive areas. Finally, I examine recent proposals to reform America's health care system by requiring all employers to provide health insurance to their employees. I argue that such proposals lend themselves to the same ethical problems that the current system does and urge greater attention to alternative reform options.     

Electronic personhood for artificial intelligence in the workplace

There are several legal and ethical problems associated with the far-reaching integration of man with Artificial Intelligence (AI) within the framework of algorithmic management. One of these problems is the question of the legal subjectivity of the parties to a contractual obligation within the framework of crowdworking, which includes the service provider, the Internet platform with AI, and the applicant's client. Crowdworking is an excellent example of a laboratory of interdependence and collaboration between humans and artificial intelligence as part of the algorithmic management process. Referring to the example of crowdworking platforms, we should ask whether, in the face of the rapid development of AI and algorithmic management, AI can be an employer equipped with electronic personhood? What characteristics does a work environment in which AI and algorithmic governance mechanisms play a dominant role? What kind of ethical implications are associated with the practical application of the concept of electronic subjectivity of AI in employment relations? This paper analyses the legal and ethical implications of electronic AI subjectivity in the work environment. The legal construction of electronic personhood is examined. The legal entity that uses AI, which manages the work process through algorithmic subordination, bears the risks resulting from such use (economic, personal, technical, and social) and full material responsibility (individual liability regime with the application of the presumption of guilt rule) in case of damage to an employee. Liability provisions can be complemented by a mandatory insurance scheme for AI users and a compensation fund that can offer support when none of the insurance policies covers the risk. A compensation fund can be paid for by the manufacturer, owner, user, or trainer of the AI and can compensate all those who suffer damage as a result of its operations. This is the direction proposed by the European Parliament, which has progressively called for robots to be given an electronic personality. The personalistic concept of work excludes the possibility of AI becoming a legal entity. Alongside legal arguments, ethical questions are of fundamental importance. The final part of the article presents the ethical implications of AI as an employer endowed with a legal entity (electronic personhood).     

Assessment of competency for execution? A guide for mental health professionals

Assessment of competency for execution presents two compelling ethical questions for mental health professionals: whether clinicians can ethically provide such assessment, and if so, how it should be done in order to maximize quality and minimize ethical conflict. In this article we address the issue of whether to participate and, if so, how. The question of whether to participate is discussed by summarizing the arguments for and against participation and offering guidelines for making a decision. The question of how to proceed is discussed in two contexts: preadjudication (before a formal decision about competency) and postadjudication (following a determination of "incompetent" and transfer of the offender to another facility for treatment and further assessment). Finally, recommendations are made regarding research that would improve the quality of execution competency assessments.     

A quasi-experimental test of the effects of criminal justice involvement on later mental health

Objectives

While many criminological theories posit causal hypotheses, many studies fail to use methods that adequately address the three criteria of causality. This is particularly important when assessing the impact of criminal justice involvement on later outcomes. Due to practical and ethical concerns, it is challenging to randomize criminal sanctions, so quasi-experimental methods such as propensity score matching are often used to approximate a randomized design. Based on longitudinal data from the Cambridge Study in Delinquent Development, the current study used propensity score matching to investigate the extent to which convictions and/or incarcerations in the first two decades of life were related to adverse mental health during middle adulthood.

Methods

Propensity scores were utilized to match those with and without criminal justice involvement on a wide range of risk factors for offending.

Results

The results indicated that there were no significant differences in mental health between those involved in the criminal justice system and those without such involvement.

Conclusions

The results did not detect a relationship between justice system involvement and later mental health suggesting that the consequences of criminal justice involvement may only be limited to certain domains.

     

The ethical implications of prospective payment and corporate medical practice: A research agenda

The major trends in the growth of prospective payment and the corporatization of medical practice in the United States are examined. In particular, the ethical implications of these changes in the context of the multiple system goals of access, cost containment, and quality are considered. Considerable concern is being expressed that with the dominant emphasis on cost containment, the principles of access and quality might be compromised. This paper formulates a research agenda to address this question, based on a review and synthesis of empirical evidence and hypotheses about the probable or actual impact of these changes on the multiple health system goals. A basic premise is that ethical judgments should be grounded in empirical evidence about what actually is or will be.     

Doctors and allocation decisions: a new role in the new Medicare

The role of the physician in the allocation of health care resources has come under renewed scrutiny in recent years. Doctors have always had to face the reality of scarce resources and to do their work in the context of social injustices. With the advent of Medicare and Medicaid came the rhetoric of universal access and the "right to health care." At the same time the field of bioethics was emerging and contributing ideas about other kinds of rights, such as the right to die with dignity. Physicians during this time did not see their role as that of gatekeeper, but rather as advocate for the best care for each individual patient. The 1980s has brought a new awareness of limited resources and the necessity for a rationale for allocation of resources. These social and professional shifts have confronted physicians with the need for yet another shift in their ethical stance. If they are to take part in allocation decisions, for the continued well-being of their patients and of the public health, they will need a new perspective on biomedical ethics. This role can be an ethical one for physicians providing certain criteria are met: there must be universal access to a basic minimum level of care, physicians' levels of income must not be directly related to treatment choices, there must be a closed financial system within which meaningful trade-offs can be made, and there must be an ethically acceptable framework for decision-making.     

The ethics of profession in dental medicine

Changes in technology, public policy, and the multi-dimensional relationships of professionals have resulted in renewed interest in the ethics of health care practitioners. This article considers the obligation of dentists to a life of morality in common with all humanity. Additional responsibilities are incurred by a practitioner of dental medicine in keeping the moral rule to "do your duty." These duties are explicated utilizing three classical characteristics of a professional. The Principles of Ethics and Code of Professional Conduct of the American Dental Association are the dental profession's guide to ethical conduct. The Principles and Code are traced in their development, reviewed in their content, and critiqued in comparison to the ethical obligations of the dentist as previously delineated. The use of the Principles and Code as a basis for professional self-government is evaluated.     

Xenotransplantation: consent, public health and charter issues

There is a growing body of literature and commentary analyzing the ethical and public policy concerns associated with xenotransplantation. While this technology holds great promise to provide an almost limitless supply of organs for transplantation, there remains grave concern about possible public health ramifications. As a result, it has been recommended that patients who undergo xenotransplantations will need to agree, inter alia, to a lifetime of close health monitoring, participation in an international database and autopsy upon death. It has been suggested that this agreement would transform the nature of informed consent into a "binding contract." Though such draconian measures are understandable given the magnitude of the risks involved, would existing common law and legislation allow their implementation? This paper analyzes relevant Canadian consent and public health law in the context of the xenotransplantation. Canada is a country with a particularly rich body of informed consent jurisprudence--jurisprudence firmly rooted (rightly or not) in the ethical principle of autonomy. In this climate, many of the suggested monitoring strategies would find little support from Canadian law. Before xenotransplantations proceed, policy makers must be sensitive to the legal barriers which exist to the implementation [of] effective public health measures. Effective surveillance programs will require novel approaches to consent and the enactment of specific public health laws.     

Public expectations of health professionals when patients telephone for medical advice

This article focuses on the ethical, social and liability implications of patients obtaining unsolicited medical advice over the phone. The ethical discussion centres on the demise of paternalism and the increase in patient autonomy and individualism and the growing public expectations of health professionals. The article then discusses the advantages and disadvantages of telephone consultations from a social and policy perspective. In light of these considerations it considers what the liability implications are for phone consultations. It argues that the ethic of individualism, coupled with recent Australian tort reforms, suggests that only in limited circumstances would a doctor be found liable for negligence in relation to telephone consultations. However, the increasing expectations being placed on medical personnel, as evidenced by the increase in unsolicited telephone consultations, if left untempered, may lead to a situation with which the health care system is ill equipped to deal.     

The changing locus of decision making in the health care sector

In the 1970s, the health policy debate focused on whether government or the medical profession should control the health care system. This article asserts that that struggle between two forms of centralized control was both less promising and less consequential than the devolution of decision-making authority upon consumers and their agents that is occurring today and that seems likely to continue as competitive forces become stronger and opportunities for meaningful consumer choice increases. What we are witnessing is the simultaneous deprofessionalization and depoliticization of important decisions affecting health care, a decentralization and diversification of the system that is opening new possibilities for translating diverse consumer desires into provider performance. Although covering much familiar ground, this article links a variety of seemingly discrete issues under the sterility of the competition-versus-regulation debate and to show the historical and ethical significance of the major changes that are under way in the health care sector today.