Healthcare touches our lives and our institutions at every level. How we live our lives, what we eat, what we do (mental and physical “exercise”), how we socialize and care for others, parents, spouse, children, friends, etc., have health and therefore healthcare dimensions.
I am currently sitting next to a hospital bed where my dad is resting. He has a naso-gastric tube, an IV, and perhaps a 50-50 chance of a trip to the OR before the weekend is over. At this point, ethics are not on my mind. I simply want an optimal health outcome for dad. But on second thought, that's all about ethics, and so is MU.
As brilliantly pointed out by doctors Stephen Miller and Alastair MacGregor, in “ Ethical Dimensions of Meaningful Use Requirements for Electronic Health Records,” Meaningful Use makes specific ethical shifts in healthcare delivery, as well as highlights ethical or moral underpinnings that are worth a moment of explicit attention. These include:
• Projected quality and safety benefits from MU could be so substantial that non-attainment may be egregious. Much more than simply the delay of a clinical and technology project without consequences, failure to meet MU staged thresholds in a timely manner might signify not only second-rate status, but confer an air of third-world competency.
• The motivation should be patients’ needs for optimal health outcomes—not a fascination with technology or incentive-seeking, or achieving a positive marketing statement, etc. How is your organization framing its MU campaign? Perhaps, “Everything we do is about helping you experience optimal health, even in sickness.”
• There will be significant pressure to make false claims about achieving MU given the breath of challenging criteria. Ironically, the pressure and desire to “do the right thing” will raise the temptation to do otherwise. That's an ethical issue. Are you at risk?
• MU will drive much greater transparency on variations in care; today, variations, such as they have seen in the Dartmouth Atlas, are comparatively crude yet objective indicators that patients’ needs aren't the primary driver of how resources are spent. How will we deal with the ensuing dialogue of “justice and equal opportunity for patients (based on need)” when the volume and quality of the data are amplified by HITECH? For more on this, see Larry Holly's Cortez Policy, here.
• The ability and MU mandate to have more “open-access” to patient care information, including the ability to “enthusiastically” share that information. Will that lead to erroneous, misinformed and harmful conclusions, with true harm, along with the true benefits of openness?
• The Miller/MacGregor article also addresses moral and ethical issues related to vendor pricing and contracting practices; clearly in contrast to practices in industries where “what the market will bear” are ethically acceptable. The whole concept of “fair and reasonable return on prior investments” has a very checkered history in healthcare. For example, when my gamma knife machine is obsolete before it's paid for (hypothetically), where I am supposed to make up the difference? How can an organization, whether budget or market-driven, plan without incorporating ROI? Should we protect ROI planning assumptions because healthcare is too important to fail?
This compelling article concludes by asking the cornerstone ethical argument: “Is meaningful use relevant to clinical practice, or is it an excessive bureaucratic requirement to spend public dollars on doctors’ (and hospitals’) computer systems?” Although I'm sure there is consensus on the former, i.e. this is all about improving clinical practice, that message is too often lost at the local and community levels.
In closing, as I look at my dad in the hospital bed and contemplate what will happen next for him, these ethical issues are far from academic. They are absolutely real. What do you think?
Joe Bormel, M.D., MPH
CMO & VP, QuadraMed
This Post: http://tinyurl.com/EthicsMU
“ Even the most rational approach to ethics is defenseless
if there isn't the will to do what is right .”