Barriers to Accountability in Health Information Technology

Let’s go over the barriers from Nissenbaum (1996).  These are “the problem of many hands”, “bugs”, “the computer as a scapegoat” and “ownership without liability” (Nissenbaum, 1996).  Let us discuss each in detail and remedies for each.

Problem of many hands

The issue with this and how it is a barrier is this.  According to Dennis Thompson (2011), when things happen we want to look for someone to hold responsibility.  In the case of large organizations (ie. Healthcare Vendors) it can be very difficult to pinpoint one person because in these organizations, many persons are involved and by pinpointing a single person it could be an unfair judgment, if they could not have prevented the event (Thompson, 2011).  On the other hand, if we hold the entire organization accountable, this could unfairly affect people that are not responsible at all (Thompson, 2011).  Thompson proposes one way around this barrier is “prospective design responsibility” (Thompson, 2011).  This is making an independent body responsible for the design of the processes that the organization must follow in order to monitor production and to avert malfunctions.  This body would then be the ones held responsible if they did not fix broken processes or ignore warnings of failure (Thompson, 2011).

Bugs

Bugs, or coding errors (or as a company I worked for called them “undocumented features”) are part of the natural process in coding computer applications.  If one were to count the lines of code for any large, complex applications, one would most likely count up into the millions of lines of codes.  Inevitably, there will be errors in the code.  These errors can be simple mistakes, things brought out by other features or on the more sinister side, they may be known and ignored.  When these cause issues they can become a barrier to accountability because one can say “it’s just a bug in the software that was overlooked.”  So how can there be accountability for the bugs that were intentionally ignored or even created?  Most of the outside sources that I found mentioned Nissenbaum, so here is what she has to say.  Basically, we know that bugs are a natural part of coding.  Here lies the problem.  Many times this causes people to use this as an excuse for sloppiness and incompletion (Nissenbaum, 1996).  This means that people need to take more accountability in their coding and testing of the software in order to keep bugs to a minimum.

The computer as the scapegoat

At times it may be easy for someone to blame the computer for faults.  This can be a plausible explanation, since we know that there are inherently bugs in any system.  Back in school I remember a saying, popular with computer-minded individuals.  “Garbage in, garbage out.”  This meant that in many cases, errors are attributed to the user and not the computer.   The information or commands given to the machine are what is responsible for the action it takes.  According to Friedman and Millett (1995), the reason that some people blame computers is because of the perceived decision making capabilities of these machines (Friedman & Millett, 1995).  The go on to say that “designers should communicate through the system that a (human) who -- and not a (computer) what -- is responsible for the consequences of the computer use” (Friedman & Millett, 1995). 

Ownership without liability

Nissenbaum discusses the barrier and states “along with privileges and profits of ownership comes responsibility” (Nissenbaum, 1996).  To me this means that if you are benefiting you should be held responsible for any errors or mishaps resulting from use.  This means both the vendor and the purchaser.  Unfortunately in the software industry it is becoming a trend to deny accountability of software produced while retaining “maximal property protection” (Nissenbaum, 1996).  The way around this barrier is through contracts and particular attention to End User Agreements.

References:

Friedman, B & Millett, L.  (1995).  "It's the Computer's Fault" -- Reasoning About Computers as Moral Agents.  Retrieved from http://www.sigchi.org/chi95/proceedings/shortppr/bf2_bdy.htm

Nissenbaum, H. (1996). Accountability in a Computerized Society. Science and Engineering Ethics, 2(1), pp. 25-42. DOI: 10.1007/BF02639315

Thompson, D.  (2011 Jan 28).  Designing Responsibility: The Problem of Many Hands in Complex Organizations.  Harvard University.  Retrieved from http://scholar.harvard.edu/files/dft/files/designing_responsibility_1-28-11.pdf

Conflicting Moral Priorities Resulting from Cultural and/or Religious Diversity

How does one decide on which moral norms should prevail in the clinical setting?

I actually found that this topic was very interesting.  Right from Chapter 1, Beauchamp and Childress (2009) state that "particular moralities…contain moral norms that are not shared by all cultures, groups and individuals" (p. 5).   To me this means that at times some may feel it is necessary to introduce their particular norms into the clinical setting, as held by their particular beliefs or culture.  This reminds me of a surgery that I underwent a few years back.  Without going into too many details, the condition was a result of certain life activities that I had been involved in.  One of the nurses took it upon herself to relay her Christian beliefs to me and to basically tell me how I needed to change my life based on her particular moral beliefs.  At the time, and because I was under duress, I did not pay much attention to her, but now I see that what she was doing had no place in the clinical setting.  You see, even though her beliefs where relevant to her, this could have caused tension between the medical facility and myself.  Richard Sloan wrote an article in the LA Times and expressed this sentiment; "we all are free to practice our religion as we see fit, as long as we do not interfere with the well-being of others by imposing our religious views on them."  He went on to say "Freedom of religion is a cherished value in American society. So is the right to be free of religious domination by others. 

So the question is which moral norms should this nurse have chosen?  Well certainly, her particular moral norms should have no place in the clinical setting.  I believe that in this setting, because of the influx of such a wide diversity of persons coming and going, all professionals should adhere to the common morality and if a particular morality is chosen it should be professional moralities that define the guidelines for health care professionals.

Beauchamp and Childress (2009) lay out 10 examples of moral character traits when it comes to the common morality.  These are non-malevolence, honesty, integrity, conscientiousness, trustworthiness, fidelity, gratitude, truthfulness, lovingness and kindness.  These are the types of traits that should be displayed first and foremost in the clinical setting.  When it comes to professional ethics, eHow.com contributor Stephanie Mitchell puts it this way, "Codes of ethics come into play when simply knowing the difference between right and wrong is not enough, and such situations arise around patients' rights, patients' dignity, equitable access to treatment and the development of new medical technologies. Medical codes of ethics help ensure that healthcare professionals make the best possible choices when faced with difficult decisions."

Beauchamp, T. L., & Childress, J. F.  (2009).  Principles of Biomedical Ethics (7th ed.).  New York, NY: Oxford University Press.

Mitchell, S. (n.d.).  The Purpose of Professional Ethics in Healthcare.  eHow.com.  Retrieved from http://www.ehow.com/info_8404364_purpose-professional-ethics-healthcare.html

Sloan, R. P.  (2008 August 23).  When religion and healthcare collide.  LA Times.  Retrieved from http://www.latimes.com/la-oe-sloan23-2008aug23,0,4637656.story

Clinical Ancillary Applications Benefits and Limitations to Integration

Being new to healthcare, I had no clue what ancillary services were.  Your Dictionary, Medical (n.d.) defines these services as being "Relating to or being auxiliary or secondary."  So since these are secondary and supplementary to the primary medical functions, why would it be advantageous for them to have their own computer systems dedicated to their functions?  What benefits are there to using systems of this nature and what are the limitations?

First off let us discuss why these services should be automated and computerized and also what is the current state of technology in regards to clinical ancillary.  As part of an abstract for a paper, Michael Minear and Jeff Sutherland (2003) wrote the following:

Digital computers have been successfully incorporated into specialized clinical instruments to offer advanced digital devices such as fetal monitors, heart monitors, and imaging equipment. But these devices are often not fully integrated with clinical management and operational systems. Beyond ancillary department applications, the result of almost 30 years of trying to automate the clinical processes in health care is large investments in both computer systems and paper medical records that have resulted in paper-based, computer-assisted processes of care.  This expensive combination of partial clinical automation and archaic paper-based support processes is a major obstacle to improvements in care delivery and management. (Minear & Sutherland, 2003)

So as you can see not having these processes computerized is causing a disadvantage to patient care process, delivery and management.  For example of how the current systems are set up in some places, let us look at the operating room (OR).  The OR is an example of leading edge technology advances, but in many cases, in many HCOs, the ancillary systems are not integrated with each other or into the core systems (Minear & Sutherland, 2003).  One of the benefits of having computerized, integrated ancillary systems is having all of the "players" related to the patient care delivery process working as a synchronized unit (Minear & Sutherland, 2003).  If this is not the case then it is hard to stay on track, stay informed and the process will suffer.  

Another advantage of ancillary applications is creation of a knowledge base.  Minear and Sutherland (2003) said that, "Knowledge-enabled software is inherently flexible and delivers much more sophisticated support to clinicians."  Another advantage is the enforcement of standards throughout the organization (Minear & Sutherland, 2003).

One limitation is the "major amount of work to rewrite and test a new system that has no guarantee of satisfying all the needs of the ancillary services (Andrews, n.d.)."  Another is the coordination of so many dissimilar projects.  Other limitations are difference data definitions for storage, formal processes to integration taken over by committees and formulating a process for management of the data.

As you can see there are benefits (correlation and standardization of care and knowledge) with clinical ancillary applications.  There are also limitations especially when it comes to integrating these into a core system.  It is up to the HCO to determine if the benefits outweigh the limitations, and this can be based on many difference factors.

References:

Andrews, R. D.  (n.d.).  Integration of Ancillary Data for improved Clinical Use: A Prototype within the VA's DHCP.  Downloaded from http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=20&ved=0CHUQFjAJOAo&url=http%3A%2F%2Fpubmedcentralcanada.ca%2Fpmcc%2Farticles%2FPMC2245652%2Fpdf%2Fprocascamc00017-0608.pdf&ei=cLkEUfyHBMzdqAHj2oCIDg&usg=AFQjCNFcLdttxcfqEXbHyP44u8A_HFVV-g&sig2=au_3UNpsjJzUZdksizXJog&bvm=bv.41524429,d.aWM

Minear, M. N. & Sutherland, J.  (2003 June).  Medical Informatics-A Catalyst for Operating Room Transformation.  Seminars in Laparoscopic Surgery, 10(2), pgs. 71 - 78.  DOI: 10.1177/107155170301000203

Your Dictionary, Medical.  (n.d.).  ancillary medical definition.  Retrieved from http://medical.yourdictionary.com/ancillary

Dreaming of the (Medical Information Technology) Future

Have you watched Star Trek lately?  What is the future of healthcare?  Will it be "trekkie" in a few hundred years.  Mobile devices that scan you and send the information back to the central computer for AI to make decisions?  Hologram doctors?  Whats in store?  We can only dream!!