Emerging technologies: Web 2.0.
Web 2.0 has brought a change to how we communicate and disseminate
information with the use of Twitter, Facebook, YouTube, instant
messaging and blogging. This technology is beginning to be used in the
health field for public awareness campaigns, emergency health alerts,
medical education and remote healthcare services. Australian Health
Information Managers will be called upon to reconcile their
organisations' policies and procedures regarding the use of Web 2.0
technologies within the existing legal framework of privacy,
confidentiality and consent. This article explores various applications
of Web 2.0, their benefits and some of their potential legal and ethical
implications when implemented in Australia.
Keywords (MeSH): Internet; Social Networks; Information Sharing; Information Dissemination; Confidentiality
Hospital information systems
Communication in medicine (Technology application)
Information storage and retrieval (Forecasts and trends)
Information storage and retrieval systems (Hospitals)
Information storage and retrieval systems (Management)
|Publication:||Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Health Information Management Association of Australia Ltd. ISSN: 1833-3583|
|Issue:||Date: Feb, 2011 Source Volume: 40 Source Issue: 1|
|Topic:||Event Code: 010 Forecasts, trends, outlooks; 200 Management dynamics Computer Subject: Market trend/market analysis; Company business management; Technology application|
|Product:||Name: Twitter (Online service)|
|Geographic:||Geographic Scope: Australia Geographic Code: 8AUST Australia|
Hospitals and medical practices are beginning to explore the newer
web-based social networking technologies as an effective way to
communicate with their patients, clients and the public. This includes
using sites such as Twitter (www.twitter.com) and Facebook
(www.facebook. com). As is typical of many emergent technologies, the
leading adopters are ahead of the legislation and have yet to fully
probe the potential ethical dilemmas that might arise from their use.
In Australia, Health Information Managers (HIMs) are bound by their professional Code of Ethics, which includes the statement that they must '[c]ontribute to the planning and development of services which enable individuals within the community to achieve optimum health' (Health Information Management Association of Australia 2009). It can be argued that the collective components of Web 2.0, which comprise Twitter, Facebook, Youtube, Instant Messaging and blogging, will play a major part in future healthcare, due to their proliferation, cost-effectiveness and ease of use. As guardians of the patient's health information in their respective healthcare facilities, HIMs will need to contribute actively to policy formation around the use of such tools, and monitor and evaluate their use.
Twitter allows a user to post a short message or 'tweet' of up to 140 characters. This message is then immediately sent to other Twitter users who have chosen to follow the posts. The messages are also publicly available for any Twitter user who chooses to search for them. The Henry Ford Hospital, in Detroit, Michigan, USA, has been using Twitter for two years, after initially adopting it as a way to access feedback from former patients about their experiences at the hospital. In January 2009, the hospital's surgical team used Twitter to post message updates about a robotic bladder removal procedure, as it was taking place. This was supported by a live video feed through to a robotic surgical conference in Las Vegas. While the general public did not see the video, the Twitter updates were widely available (Bush 2009). The hospital has gone on to 'tweet' more surgical procedures as they have taken place, including a donor-to-recipient kidney transplant. On 16 October 2009 this surgical procedure was posted to Twitter, tracking the progress of removal of the kidney from the donor through to its implantation in the recipient. (For example, one of the final messages of the session was 'The kidney is in', shortly followed by 'Right away, it is already producing urine'.) (1)
Arguably, educational benefit can be used to justify the posting of Twitter updates as a surgical procedure progresses. Another operative procedure Twittered by the Henry Ford Hospital was the removal of a kidney tumour. This procedure normally would have resulted in the removal of the entire kidney; however, in this case, the tumour was removed by partial nephrectomy. The educational value of the contemporaneous posting was evident in the demonstration that the surgery could be completed without total nephrectomy, thus resulting in a better patient outcome (Pincock 2009). The Henry Ford Hospital continues to twitter about live surgery, and now publishes case information prior to the event. (2)
Notwithstanding the success of the public broadcasting of a surgical procedure, ethical and legal issues do arise; for example, via Twitter confidentiality could be compromised. Using the state of Victoria as the exemplar, the Health Records Act 2001 (Vic) (3) requires that patient consent be obtained with regard to the disclosure of information as per Health Privacy Principle HPP 2 (Use and Disclosure). (4) HIMs would need to review the consent process to ensure that patients fully understand the technology and what it means to have their procedure 'Twittered'. Strategies and policies need to be formed around what happens in the case of complications occurring during surgery: Should the procedure continue to be broadcast? What if the complication was caused by a surgeon's error? The Henry Ford Hospital deals with these potential eventualities via plans to suspend the Twitter updates in the event of complications. The hospital also evaluates cases carefully and only posts about procedures that are regularly performed with minimal risk (Bush 2009).
Recording of patient information
In the Australian context, there is also need for consideration of the recording of the information. For completeness, the 'tweets' would have to be part of the patient's Unit Record, as stated in HPP 3 (Data Quality) of the the Health Records Act 2001 (Vic), which requires organisations to take reasonable steps to ensure that 'health information it collects, uses, or discloses is accurate, complete, and up to date'. In organisations still using paper-based records, HIMs would have to manage the printing of a Twitter report and the associated filing process required. The associated time and cost impact on the Health Information Service would have to be considered, along with the benefit to be gained. This consideration would ultimately become obsolete with the implementation of electronic health records. It is feasible that these communication tools may become an integrated part of electronic health record systems, with the Twitter report generated automatically and in real time, that is, in the patient's medical record, as the clinical event occurs.
In Australia, a certain level of healthcare is guaranteed to be accessible by all, and this raises the issue of limited resources and its effect on compliance by health professionals, hospitals and other facilities, with the bioethical principles of justice and beneficence (Kerridge, Lowe & Stewart 2009). Web 2.0 technologies can assist in the management of scarce resources and the distribution of health services. Patients/clients have a right to a certain level of care; however, the geographical distances in countries as large as Australia create challenges to the provision and maintenance of services to rural areas. In Brooklyn, New York, a general medical practice called Hello Health has set up a secure portal through which it manages its practice and maintains contact with its patients. For a monthly fee of $US35, patients can email, instant message or even video chat with the general practitioners, and this can alleviate the need for appointments for minor complaints. Repeat prescriptions are issued online and test results obtained without the need for the patient to telephone the practice in an attempt to speak to their doctor who, inevitably, is busy seeing another patient (Hawn, 2009). Doctors can increase their efficiency and time usage by managing minor complaints in less time, thereby increasing their productivity. The application of this technology to the Australian rural setting could mean that country doctors could treat more patients, thus better meeting rural patients' rights to accessible health care.
This model could be further expanded to meet the need of rural patients where a metropolitan general practitioner (GP) or hospital clinic is providing the online contact. Legal considerations arise when using video conferencing and email to treat patients remotely. For example, in an effort to provide care to patients in remote areas, a Californian company was contracted to provide a video conferencing diagnostic service to Hawaii; however, doctors providing the service were only registered in the State of California and therefore clinicians have had to register to practice in the state of Hawaii (Hawn 2009). There were similar implications for Australia as previously health professionals were registered on a state-by-state basis. However, the Health Practitioner Regulation National Law Act 2009 came into effect on 1 July 2010 and has been enacted by all states and territories except at time of writing, for Western Australia. (5) This is the first step towards removing state boundaries affecting where a clinician may be permitted to practice.
There remain issues around standards of care that are yet to be addressed (Hawn 2009). The question might be asked: how far can a diagnosis progress without the doctor conducting a physical examination of the patient? Guidelines would need to be developed for acceptable best practice for online consulting. Currently, the Australian Medical Association (AMA) policy is that online consultations cannot replace face-to-face appointments except for repeat prescriptions (Pincock 2009). Until this situation changes, adoption of Web 2.0 technology will be somewhat hampered. This raises the hypothetical ethical question of whether the AMA policy is inadvertently preventing rural GPs from practising beneficence in the context of preventing potential harm to patients who are unable to obtain an appointment in a timely manner. If rural practitioners could communicate securely online with their patients, they would be able to allocate their appointment times (a limited resource) based on clinical need, and still be able to advise patients who do not need an appointment.
Some public health benefits
Web 2.0 technologies have already proven to be extremely effective for the dissemination of public health and emergency information. The Centers for Disease Control and Prevention (CDC) has actively embraced sites such as Twitter, Facebook, Myspace and Youtube, using these to distribute information about the H1N1 influenza outbreak in 2009 (Currie 2009). Updates were received immediately more cases were reported. Progressively, as they began to define the strategy for managing the epidemic, the CDC also published information about briefing sessions for doctors (Pincock 2009). The Henry Ford Hospital, Detroit, uses Twitter to inform on localised health warnings and press releases (Bush 2009). They have also posted a Facebook page with information about breast health in Breast Cancer Awareness month, with a viral marketing message attached to promote circulation. (6)
The immediacy of information released from organisations helps health practitioners and organisational providers to comply with the bioethical principle of veracity (truthfulness). If pertinent, reliable information is regularly released in an easily accessible manner, this can create the perception that the organisation is trustworthy. Organisations that actively engage their clients and the general public in communication create an impression of transparency of actions; issues are seen to be freely available and, therefore, the organisation is perceived to be acting with veracity.
Health Information Managers
Health Information Managers will play an important role in the inevitable adoption of Web 2.0 technologies. In order to comply with the HPPs of the Health Records Act 2001 and the Privacy Acts (Privacy Act 1988; Privacy (Private Sector) Act 2000), HIMs will need to ensure that electronic and manual systems alike can adapt to receiving information from online collaboration and communication tools. There is also a critical role to be played by HIMs in providing education to clinicians on documentation protocols. Awareness about the potential audience for a Twitter broadcast operation report is essential. The requirements for confidentiality and privacy will remain paramount and it may be more prudent to tailor the use of the Web 2.0 technology to specific functions, rather than adopt a universal usage; for instance, public press releases on general interest items about a healthcare facility would be appropriate for rapid dispersion through Twitter. Conversely, a social network platform like Facebook may be prudently limited and doctors could be encouraged to use a secure restricted forum. By way of example, Multimedix, the 'online community for doctors' (7) in Australia allows doctors to find colleagues, discuss cases, and look for feedback on clinical issues in a secure online mode (Pincock 2009). Similar platforms exist with Sermo (8) in the USA and Doctors.net.uk in the United Kingdom. All existing applications have the potential to enable faster and more efficient communication between patients and their doctors, and amongst health professionals. It is important, nonetheless, to use the correct tool for the correct purpose.
As new health professionals emerge from universities, no doubt they will increasingly utilise fully integrated Facebook and Twitter in their standard way of communicating with their peers, and the push to adopt these communication methods in a professional capacity will accelerate. In 2009, the number of Australians using Twitter had increased by 1000% since 2008 (Pincock 2009). We might reasonably predict that Health Information Managers will become integral in optimising the benefit to patients' health to be gained by effectively managing the technology challenges, posed by emergent communication modes, to ethical and legal practice.
Bush, H. (2009). Time to Tweet? Hospitals & Health Networks 83(6): 46-48.
Currie, D. (2009). Public health leaders using social media to convey emergencies: new tools a boon. The Nation's Health 39(6): 1-10. Available at: http://thenationshealth.aphapublications. org/content/39/6.toc
Hawn, C. (2009). Take two aspirin and Tweet me in the morning: how Twitter, Facebook, and other social media are reshaping health care. Health Affairs 28(2): 361-368.
Health Information Management Association of Australia (2009). Code of Ethics. Available at: http://www.himaa.org.au/Pubs/Cod e%20of%20Ethics%20HIMAA.doc (accessed 30 April 2010).
Kerridge, I., Lowe, M. and Stewart, C. (2009). Ethics and law for the health professions (Third edition). Sydney, The Federation Press.
Pincock, S. (2009). Tweeting the sick. Australian Doctor 12 May: 1718. Available at: http://www.australiandoctor.com.au/search. asp?I2=highlight&mapmode=off&I3=Tweeting+the+sick&ima ge1.x=0&image1.y=0
(1) The full twitter transcript is available at http://www.henryford.com/ body.cfm?id=52828
(2) Available at: http://www.henryford.com/body.cfm?id=5ll68
(3) Available at: http://search.austlii.edu.au/au/legis/vic/consol_act/hra200ll44/
(4) The Health Privacy Principles can be downloaded from www.health.vic.gov. au/hsc/downloads/hppextract.pdf
(5) Available at: http://www.ahpra.gov.au/documents/default.aspx?record=WDl0 %2fl563&dbid=AP&chksum=blYsKvtKyhHdnDKio5ERFA%3d%3d
Claire Holt BHIM Honours Candidate
Health Information Management Department
School of Public Health
La Trobe University
Bundoora VIC 3086
Previously, Nursing Education Administration Co-ordinator
Royal Melbourne Hospital
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