As a result of criminal and civil charges earlier this year, Practice Fusion agreed to pay $145 million in restitution related to intentionally designing an electronic health record system to influence physicians to prescribe more opioids. The company admitted to receiving payments from an opioid manufacturer in exchange for using the software to influence prescriptions.
For me, this is both personal and professional.
Last year, my high school friend died from a drug overdose that began as an addiction to prescription painkillers. I’m also a professor of computer science and general internal medicine at DePaul University and Northwestern University; I teach courses in health informatics and human-computer interaction.
My research and teaching career is dedicated to improving human well-being with human-centered, effective, efficient and safe technology design. I’ve also been studying how doctors and patients interact with electronic health records since the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.
Health information technology developers need to adhere to the same ethical standards as physicians. Each year, new physicians take an oath to do more good than harm and act in the best interest of patients.
Yet there is no ethical oath for the 65,000 students who graduate each year with a computer science degree in the United States. Since health care will continue to rely on technology, physicians need to trust that the tools they use are designed with the same ethical standards that medicine is based on.
The Association for Computing Machinery has a code of ethics that emphasizes avoiding harm and promoting usability. But nothing prevents anyone—including students—from ignoring such appeals to conscience in using their knowledge to design for personal gain and harm.
Poor usability and oversight of electronic record design have contributed to new burdens for health care workers and safety issues. Usability is the degree to which a person can accomplish a task using technology effectively, efficiently and safely.
Health care providers report electronic health record related errors due to improper dosing in pediatric settings, and in intensive care units, 34 percent of the errors are electronic health records related. Medical error is the third leading cause of death in the U.S. Many physicians report burnout related to electronic record design.
Our research published in Academic Emergency Medicine describes an attempt to reduce opioid disorder by implementing a reminder for emergency physicians to counsel patients who have been prescribed opioids, as well as by using improved medication sheets for patients to understand how to properly take their medication.
Improving the design of systems for prescribing and counseling about opioids would improve patients’ knowledge about opioid risks and influence their behavior. In 2019, researchers submitted 59 papers to the journal Academic Emergency Medicine about opioid use disorder, reinforcing the dedication of clinicians and researchers to making a positive impact on the epidemic.
Electronic health records were at the center of our study because that is where we could best capture physician attention. Research in primary care shows that some physicians spend about 50 percent of patient visits looking at the screen. Despite these efforts, patient behavior did not change.
Having a friend or family member with opioid addiction is common for millennials, as millennials and Gen Z are most affected by opioid addiction and death. From 1999 to 2017, more than 700,000 people died from a drug overdose.
An estimated 10.3 million Americans aged 12 or older misused opioids in 2018. According to the National Safety Council, a person in the U.S. is more likely to die from an opioid overdose than a car crash. The opioid epidemic is an ongoing public health emergency.
Certainly, this is just one urgent health emergency, and applying ethics in the system of maintaining health records is essential in every instance.
In the HITECH Act over a decade ago, the U.S. government designated $36.5 billion for the digitization of the health care industry with electronic health records. The intention was to reduce medical errors and burdensome paperwork.
The Office of the National Coordinator for Health Information Technology (ONC) is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and electronic exchange of health information.
A JAMA study of ONC-certified systems found that 275 systems had an issue with the potential for patient harm. Before 2017, the ONC had mandatory random surveillance of 2 percent of electronic health record systems, but this is no longer a requirement.
The lack of regulation for these systems motivated Medstar Health to draft a letter to Congress in 2019 requesting specific measures of usability and a method for physicians and patients to report usability and safety. That way they can act on medical errors.
Without oversight of technologies core to the provision of health care, the health system is vulnerable to corruption. Increased oversight of electronic health records systems on many levels will prevent harm and save lives.
Engineering and computing students developing these systems need more rigorous ethics courses. Perhaps hiring companies need to consider the grades on ethics course as equally important towards career success as grades on technical courses.
Patients can take an active role in understanding the limitations of the technology used in their care. Policymakers can educate themselves on the issues related to health information technology design and encourage standards and oversight related to improved usability. Care providers can continue to advocate for improved work conditions that contribute to patient safety. Continuous usability testing of the technologies can lead to the identification of serious errors before harm is done.
Patients and physicians trust that the electronic health records they use will keep patients safe. Increased oversight will help catch errors before they turn into deaths. It can also possibly reduce the risk of corruption from designers who intend to harm for profit.