Chapter 12: Ethical Issues in Health Information Management

What are the HIM professional’s core ethical obligations?
~Preserve the personal health information.
~Protect patient privacy and confidential information.
~Assure security of that information.
Moral Intelligence
Is important for understanding the complexity of the issues faced and how values, goals and actions are applied, in ethical decision making.
Why does the focus of technology and human relationships, increase ethical imperatives?
Because, what is done, how it is done, and what the intended (and sometimes unintended) outcomes are must be carefully examined.
Autonomy
The core ethical principle centered on the individual’s right to self-determination that includes respect for the individual; in clinical applications, the patient’s right to determine what does or does not happen to them in terms of healthcare.
Beneficence
A legal term that means promoting good for others or providing services that benefit others, such as releasing health information that will help a patient receive care or will ensure payment for services received.
Nonmaleficence
A legal principle that means do no harm.
Justice
The impartial administration of policies or laws that takes into consideration the competing interests and limited resources of the individual or groups involved.
Moral Values
A system of principles by which one guides their life, usually with regard to right and wrong.
Ethical Agent
An individual who promotes and supports ethical behavior.
Ethics
A field of study that deals with moral principles, theories, and values; in healthcare, a formal decision-making process for dealing with the competing perspectives and obligations of the people who have an interest in a common problem.
Ethical Decision Making
The process of requiring everyone to consider the perspectives of others, even when they do not agree with them. It requires people to explore choices beyond the perspective of simple right or wrong (moral) options.
Ehticist
An individual trained in the application of ethical theories and principles to problems that cannot be easily solved because of conflicting values, perspectives, and options for action.
Bioethics
A field of study that applies ethical principles to decisions that affect the lives of humans, such as whether to approve or deny access to health information. It involves problems or issues regarding clinical care of the health information system that are never strictly theoretical in nature and must always result in a decision and an action.
Privacy
The right of an individual to be left alone. It includes freedom from observation or intrusion into one’s private affairs and the right to maintain control over certain personal and health information.
Confidentiality
A legal and ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure.
Security
Includes the physical and electronic protection of the integrity, availability, and confidentiality or computer-based information and the resources used to enter, store, process, and communicate it; and the means to control access and protect information from accidental or intentional disclosure.
What does the responsibility of the HIM professional include?
~Ensuring patient privacy and confidential information is protected.
~That security measures are used to prevent unauthorized access.
~Ensuring that the release policies and procedures are accurate and up-to-date.
~That the release policies and procedures are followed.
~That all violations are reported to the proper authorities.
What does HIPAA include?
~Privacy ~Information Standards ~Data Integrity ~Confidentiality ~Data Security
What are some of the provisions of the 2009 ARRA legislation that affect HIPAA?
~The application of the security and privacy provision to business associates.
~The notification requirements in the event of a breach.
~The educational requirements regarding health information privacy.
~The restrictions on the disclosure and sale of health information.
~The accounting requirements of certain protected health information disclosures.
~Auditing Standards
~Other related issues.
What was part of the impetus (push) for HIPAA?
The development of the electronic health record.
As patients become more aware of the misuses of information, they are reluctant to share information with their healthcare team. What are some of the problems that can result from this?
~The healthcare provided. ~The information given to researchers, insurers, the government, and the many other stakeholders who legitimately need to access the information.
Accountable Care Organizations (ACO)
Intended to pay providers in a way that encourages collaboration, discourages supplier induced demand, and rewards high-quality care.
What do important health information issues include?
~What information should be collected.
~How the information should be handled.
~Who should have access to the information.
~Under what conditions the information should be disclosed.
Health information ethical and professional values are based on, what?
Obligations to the patient, the healthcare team, the employer, the interests of the public, and oneself, one’s peers, and one’s professional associations.
With regard to the patient and the healthcare team, the HIM professional is obligated to:….?
~Protect health, medical, genetic, social, personal, and adoption information.
~Protect confidential information.
~Provide service to those who seek access to patient information.
~Preserve and secure health information.
~Promote the quality and advancement of healthcare.
~Function within the scope of responsibility and restrain from passing clinical judgement.
What are some examples of the kind of information that is included in clinical information?
~Diagnoses ~Procedures ~Pharmaceutical Dosages ~Genetic Risk Factors
What are some examples of behavioral information?
~Use of drugs or alcohol ~High risk hobbies ~Sexual habits
Why is it important to protect genetic and social information?
So patients will not be vulnerable to the risks of discrimination.
What does protecting confidential information involve?
~Ensuring that the information collected and documented is protected by all members of the healthcare team and by anyone with access to the information.
~Protection of verbal communications on behalf of a patient and can involve communication with those in the legal profession, the media, or others who seek patient information.
What individuals may request access to patient information?
~Healthcare providers (insurance, research or pharmaceutical companies.)
~Government agencies
~Employers
The preservation and security of health information includes, what?
Obligations to maintain and protect the medium that stores the information, such as paper documentation and information stored in EHRs, including the protection of all databases and detailed secondary records and registries.
What might a HIM professional need to become an expertise in and why?
Clinical medicine, Pharmacology, Biostatistics, and Quality Improvement Methodologies, so as to interpret clinical information and support research, based on work responsibilities.
With regard to the employer, the HIM professional is obligated to:…..?
~Demonstrate loyalty to the employer.
~Protect committee and task force deliberations.
~Comply with all laws, regulations, and policies that govern the health information system.
~Recognize both the authority and the power associated with the job responsibility.
~Accept compensation only in relationship to work responsibilities.
How can loyalty to an employer be demonstrated?
By respecting and following the policies, rules, and regulations of employment unless they are illegal or unethical.
What should the HIM professional keep up-to-date with?
~State and Federal Laws ~Accrediting and Licensing Standards ~Employer Policies and Procedures ~Any other standards the affect the health information system.
To be sure the HIM expertise is presented and understood, where must the HIM professional be present?
At strategic meetings with clinical providers, administrative staff, and financial and operations management personnel.
What does ‘Accept compensation only in relationship to work responsibilities’, mean?
Don’t take bribes.
With regard to the public interest, the HIM professional is obligated to: ….?
~Advocate change when patterns or system problems are not in the best interests of the patients.
~Report violations of public standards to the proper authorities.
~Promote interdisciplinary cooperation and collaboration.
With regard to the HIM professional, what does ‘change agent’ mean?
Lead initiatives to change laws, rules, and regulations that do not ensure the integrity of patient information, including the protection of privacy and confidentiality.
Where should the HIM professional be proactive?
Protecting patients, the healthcare team, the organization, the professional association, peers, and themselves.
As an important member of the healthcare team, the HIM professional should work with others to, what?
Analyze and address health information issues, facilitate conflict resolution, and recognize the expertise and dignity of his or her fellow team members.
With regard to self, peers, and professional associations, the HIM professional is obligated to:…..?
~Be honest about degrees, credentials, and work experiences.
~Bring honor to oneself, one’s peers and one’s profession.
~Commit to continuing education and lifelong learning.
~Strengthen health information professional membership.
~Represent the health information profession to the public.
~Promote and participate in health information research.
Bring honor to oneself, one’s peers and one’s profession, refers to what?
Personal competency and professional behavior.
In general, the HIM professional’s primary responsibilities include those related to:…..?
Designing and Implementing a system to ensure the completeness, accuracy, integrity, and timeliness of health information.
What information crime is one of the fasting growing ethical issues?
Medical Identity Theft
Where is the strongest clustering of medical identity thefts in the United States?
~Florida ~California (especially southern California) ~New York ~Arizona ~Texas
What is Medical Identity Theft?
An information crime that occurs when an individual’s health information is misrepresented and used by an unauthorized individual to obtain healthcare goods, services, or money to which they are neither eligible nor entitled.
Why is it almost impossible to detect or correct medical identification fraud?
Because medical information systems have multiple access points across the continuum of the healthcare system.
What are the two parts of the HITECH proposed rule on HIPAA under the HITECH Act of 2011?
~The right to an accounting of disclosures.
~The right to a report on access.
How do audit trails help prevent fraud?
By identifying both internal and external disclosures, rather than allowing the EHRs to exacerbate the problem.
How can data be entered into the health information system?
~Manually ~Electronically ~Through PDAs ~Through Wireless Systems ~From Laptops
What can HIM professionals do as part of patient advocacy roles?
~Facilitate the patient’s ability to review and correct errors in their medical records
~Prevent discrimination.
~Pay attention to their pleas if they think they are victims of medical identity theft.
~Reconsider the importance of analysis.
~Consider advocacy to amend the HIPAA rules and regulations related to accounting of disclosures to include problems related to internal participants.
~Participate in HIM research studies that help identify occurrences and sources of medical identity theft.
~Conduct needed risk assessments as the NHIN becomes more of a reality, the EHR can make this crime easier.
~Design systems that can assess employees’ integrity and accountability.
~Design educational programs to ensure that colleagues understand and value the HIM Code of Ethics.
~Consider establishing policies so that patients who are victims of medical identity fraud do not have to pay for the costs of duplicating their files.
Why is a code of ethics important?
It helps guide the decision-making process and can be referenced by individuals, agencies, organizations, and bodies (such as licensing and regulatory boards, insurance providers, courts of law, agency boards of directors, government agencies, and other professional groups), among others.
Why have healthcare facilities, increasingly, abandoned the practice of charging patients for copies of their health records?
Because of the rationale that the information belongs to them and providing copies is an important customer service.
Retrospective Documentation Practices
Those where healthcare providers add documentation after care has been given for the purpose of increasing reimbursement or avoiding a medical legal action.
Unacceptable Documentation Practices
Practices that include backdating progress notes or other documentation in the patient’s record and changing the documentation to reflect the known outcomes of care (versus what was done at the time of the actual care).
What are three primary ethical problems that are pertinent to the release of information (ROI)?
~Violations of the need-to-know principle
~Misuse of blanket authorizations
~Violations of privacy that occur as a result of secondary release of information procedures.
Need-to-Know Principle
The release-of-information principle based on the minimum necessary standard that means that only the information needed by a specific individual to perform a specific task should be released.
How could a patients privacy be violated as a result of the release of information?
Through subsequent discrimination via documentation that reveals social habits, genetic risks, and family history of disease, that have nothing to do with the medical condition being treated.
Blanket Authorization
An authorization for the release of confidential information from a certain point in time and any time thereafter.
What is the problem with blanket authorizations?
There is no way for the patient to know that the information is being accessed.
Secondary Release of Information
A type of information release in which the initial requester forwards confidential information to others without obtaining required patient authorization.
What criteria must be factored into the HIM professionals decision making?
~Cost ~Technological Feasibility ~Federal and State Laws ~Medical Staff Bylaws ~Accreditation and Licensing Standards ~Employer Policies, Rules, or Regulations ~Ethical Principles ~Professional Values
What is the eight-step process to guide ethical decision making?
(1) What is the ethical question?
(2) What facts do you know and what do you need to find out?
(3) Who are the different stakeholders, what values are at stake, and what are the shared and different obligations and interests of each of the stakeholders?
(4) What options for action do you have?
(5) What decision should you make and what core HIM values are at stake?
(6) What justifies the choice and what are the value-based reasons to support the decision?
(7) What choice or choices cannot be justified?
(8) What prevention options can be put into place so that this issue will not come up again?
What are some of the issues raised because of the uses of information?
~Clinical Code Selection and Use ~Quality Review ~Research and Decision Support ~Public Health ~Managed Care ~Clinical Care
What are some ethical problems that are directly linked to coding and payment for care?
~Pressure to code inappropriate levels of service. ~Discovering misrepresentation in physician documentation. ~Miscoding to avoid conflicts. ~Discovering miscoding by other staff. ~Lacking the tools and educational background to code accurately. ~Being required by employers to engage in negligent coding practices.
What are some fraud and abuse problems?
~Documentation that does not justify the billed procedure. ~Acceptance of money for information. ~Fraudulent retrospective documentation on the part of the provider to avoid suspension. ~Code assignment without physician documentation.
What are some of the contributing factors to the ethical problems faced by quality management professionals?
~The rising cost of healthcare. ~Limited resources ~Concerns with patient safety.
What are some of the common quality outcome problems?
~Inaccurate performance data that are inappropriately shared with the public. ~Negative care outcomes, such as infections, that occur in the course of providing home healthcare. ~Failure to check a physician’s licensure status. ~Incomplete health records hidden in preparation for accreditation or licensure surveys. ~Patterns of inappropriate healthcare.
What do research and decision-support responsibilities include?
~Ensuring data integrity and confidentiality. ~Ensuring compliance with human subject research protocols. ~Maintaining and enhancing professional competence.
What conditions require mandatory state and local reporting?
Infectious and Communicable Diseases.
What poses new ethical dilemmas in the management of health information?
~New threats of Bio-terrorism
~Global Infections such as, Anthrax, SARS, H1N1, and Avian Flu.
So medical crises can be resolved, what needs to be balanced?
Patient Privacy and Public Health
What are some of the job responsibilities involved with strategies regarding pricing, access to providers and quality of care?
~Providing information about provider practices.
~Providing patient clinical and demographic information.
~Establishing policies and procedures that provide for patient privacy.
What are some of the difficult decisions that must be made, with regard to end-of-life decisions?
~Aging. ~Frailty ~Autonomy of those near death ~Physician bias and equity ~Treatment choices ~Treatment goals ~Beneficence ~Advance Care Planning ~Palliative Care ~Managing Pain
What are some of the sensitive ROI topics that are faced with ethical decisions?
~Genetic ~Drug and Alcohol Use ~Psychiatric ~Communicable Disease ~Adoption Information
What are the two levels of genetic information that can be reported in an information system?
~Presence of a Disease. ~Presence of a Risk of Disease
What are some of the issues, related to genetic information, that the HIM professional must be aware of?
~Genetic research and testing can give researchers, clinicians, and patients a means to prevent, treat, or screen for a disease.
~Insurers and employers may seek genetic information to identify at-risk individuals and deny them employment or insurance coverage, fire them, or raise their premiums.
~It is difficult to provide special protections for genetic information as a category because it cannot be clearly separated from other medical information.
~The HIPAA Privacy Rule provides a basic level of privacy and confidentiality protection for protected health information however, it does not preempt state laws that offer a higher level of privacy protection.
~The generation of experimental data by a research protocol is not specifically addressed by most state laws.
~HIM professionals have the responsibility to ensure that their practices are guided by state and federal laws and regulations to protect genetic information and by ethical imperative to protect the privacy and confidentiality of patients.
What are two reasons genetic information may be sought?
~Custody Battles ~Third-Party Liability
What is the best way to protect genetic information?
Strengthen privacy and confidentiality protections for medical information in general and to enact anti-discrimination legislation.
What are some of the national codes and international agreements, and agencies that review research proposals with a focus of protecting research participants?
~The Nuremberg Code ~The Helsinki Agreement ~The National Research Act of 1974 ~The Belmont Report ~Bioethics Commissions ~HIPAA ~IRB
What are the ethical principles that are engaged in research?
~Respect for autonomy (self-determination) ~Beneficence (promoting good) ~Nonmaleficence (do no harm) ~Justice (fairness)
What does the respect of autonomy require?
An ability of the participant to understand and authorize the research through informed consent.
What does beneficence require?
That benefit is possible.
What does nonmaleficence require?
That patients will not be intentionally harmed.
What does justice require?
Fairness in the enrollment of participants.
With regard to research projects, who is included in ‘vulnerable populations’?
~Children ~Persons who are cognitively impaired ~Comatose ~Drug Addicts ~Economically Disadvantaged ~Elderly ~Institutionalized ~Non-English speaking employees ~Low Literacy Persons ~Minorities ~Persons involved in illegal activities ~Pregnant Women ~Babies (fetuses) ~Neonates ~In-Vitro ~Prisoners ~Students (over the age of 18)
The advent of electronic information system has presented complex challenges with regard to what?
~Record Integrity and Information Security ~Integrated Linkage of Information Systems across a continuum of care ~Software Development and Implementation ~The Protection of Information in e-Health Systems
What are some of the ethical challenges facing HIM professionals, with regard to the EHR?
~Developing and maintaining information and systems security.
~Exchanging information within and across jurisdictions.
~Executing technical and clinical services contracts.
~Handling release of information.
~Implementing and managing telehealth applications.
~Maintaining and documenting compliance with HIPAA and state privacy rules.
~Maintaining the legal electronic medical record.
What does some of the HIM professionals continuing education, as Interdisciplinary Facilitator, include?
~Organizational Development ~Team Building ~Conflict Resolution
Why is data resource management included in the expertise of the HIM professional?
Because EHRs generate data repositories and huge amounts of health information of interest to many people.
To the HIM professional, advocacy is, what?
Ethics in Action: choosing to take a stand for and speak out for the rights or needs of a person, group, organization, or community.
What are some of the HIM problems that require advocacy?
~Protecting the privacy of prominent citizens.
~Demonstrating compassion for drug-dependent peers.
~Protecting the work environment for HIM employees.
~Ensuring that consent forms are properly designed so that patients understand what they are signing and so that patient information is protected from unauthorized secondary disclosure.
What does the advocacy role require?
~HIM Expertise ~Ethical Expertise ~An Understanding of the Patient’s Bill of Rights
What are some of the ethical dilemmas faced by vendors?
~What issues are raised when vendors are also friends?
~What is the appropriate use of gifts?
~Should some vendors be preferred when dealing with requests for proposals?
~How can you assure ethical dealings when negotiating contracts?