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09/24/2014

Clinical Informatics: Old Art, New Science

by Eric Swirsky, JD, MA

Through the millennia the science and practice of medicine have evolved and along with them the moral relationship that exists between doctor and patient.  While much has changed, the need for information exchange has not; it is a central component of the doctor-patient relationship and shapes its moral status.  The practice of medicine has been transformed with the rise of the health care industry. Traditional clinical values, such as respecting autonomy, promoting what is best for the patient, refraining from harm, and upholding principles of justice, have been joined by business needs for efficiency, cost effectiveness, and increased productivity. Changing policies and requirements for clinical documentation have influenced the type of information that is needed; who needs it; and how that information is recorded, stored, accessed, and exchanged.  Due to this diversity of interests, values can and do come into conflict and ethical issues arise. Although informaticians and information management specialists have been addressing with these matters for some time they have not received much attention from clinical ethicists, and that must change.  These concerns must be harmonized because nowhere are the conflicts more evident than in the clinical use of health information technology (HIT).

Computers are now ubiquitous in clinical contexts and have had a palpable effect upon the doctor-patient relationship and the practice of medicine in general.  HIT has come to fulfill a variety of functions and serve many masters along the course of its evolution.  Recognizing this is of critical importance because organizational dynamics and power relationships between front-end clinician users and back-end administrators, which can distort perceptions of technological benefit and therefore functionality, are commonly ignored (Wears and Berg 2005).  The result is that business interests are at times satisfied at the expense of clinical usability.

The influence of economic concerns affects HIT at various levels of its life cycle; it shapes design and development, drives evaluation, and funds implementation decisions. Unintended consequences on clinical practice include an increase in time on documentation and justification; fragmentation due to systematic structuring of information; changes to workflow that impact documentation quality (e.g., cutting and pasting of clinical notes); and information overload, which impedes the clinician’s and patient’s ability to discern important information.  Furthermore, the notion of confidentiality has been turned on its head due to the increased access to patient information—so much so that confidentiality has been labeled “a decrepit concept” that needs to be reevaluated (Siegler, 1982). These failings reflect the sociotechnical interplay between technology, corporate operating structures, and clinical environments, and there is a resulting impact upon patient outcomes.  If there are concerns regarding the veracity, privacy, confidentiality, usability or fidelity of the record, then its clinical utility diminishes; when systems are not meaningfully tailored to the needs of clinicians in delivering care, the technological interventions are not likely to be efficacious (Wears and Berg, 2005).

None of this is to say that business values have no place in clinical HIT environments; however, there are a host of benefits and burdens to weigh.  In doing so it is essential that we differentiate and address the needs of clinicians and administrators separately so as not to conflate their residual effects.  Technological innovation does not ensure clinical quality.  Sir William Osler, the father of modern medicine, recognized this over 100 years ago when he wrote, “The old art cannot possibly be replaced by, but must be absorbed in, the new science” (Osler, 1907).  Applying this to HIT we can already see that having advanced systems of information exchange does not guarantee improved health outcomes.  As such, it is incumbent upon clinical ethicists to look to the virtues of the technology and those who seek to employ it so that their voices may be heard above the din, and join the discourse required for tailoring HIT to meet its intended clinical goals.

Osler, W. (1907). The reserves of life. St. Mary’s Hospital Gazette, 13:95–98.

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