My aim in this paper is to give a philosophical analysis of the relationship between contingently available technology and the knowledge that it makes possible. My concern is with what specific subjects can know in practice, given their particular conditions, especially available technology, rather than what can be known “in principle” by a hypothetical entity like Laplace’s Demon. The argument has two parts. In the first, I’ll construct a novel account of epistemic possibility that incorporates two pragmatic conditions: responsibility and (...) practicability. For example, whether subjects can gain knowledge depends in some circumstances on whether they have the capability of gathering relevant evidence. In turn, the possibility of undertaking such investigative activities depends in part on factors like ethical constraints, economical realities, and available technology. In the second part of the paper, I’ll introduce “technological possibility” to analyze the set of actions made possible by available technology. To help motivate the problem and later test my proposal, I’ll focus on a specific historical case, one of the earliest uses of digital electronic computers in a scientific investigation. I conclude that the epistemic possibility of gaining access to scientific knowledge about certain subjects depends (in some cases) on the technological possibility for making responsible investigations. (shrink)

To one side of the wide third-floor hallway of Victoria College, just outside the offices of the Institute for the History and Philosophy of Science and Technology, lies the massive carcass of a 1960s-era electron microscope. Its burnished steel carapace has lost its gleam, but the instrument is still impressive for its bulk and spare design: binocular viewing glasses, beam control panel, specimen tray, and a broad work surface. Edges are worn, desiccated tape still feebly holds instructive reminders near control (...) dials; this was once a workhorse in some lab. But it exists now out of time and place; like many of the scientific instruments we study, it has not been touched by knowing hands in decades. (shrink)

Studies of academic dishonesty typically rely on potentially inaccurate self-reports or on actual behavior during less realistic tasks. Eliminating the drawbacks of such approaches, we assessed cheating during completion of actual coursework via electronic records of online behavior. Thirty-six college students completed unproctored, online quizzes. The majority of students responding to a follow-up questionnaire reported that they never considered consulting online sources during the quizzes. Computer logs reveal that although some students accessed relevant online information during the quizzes, (...) many did not: 6 instances over 72 quiz attempts are attributable to 3 or 4 individuals. Although online environments may offer more opportunities for academic dishonesty, electronic records of online activity provide a valuable and objective means of detecting such dishonesty. (shrink)

Breaches of electronic medical records constitute a type of healthcare error, but should be considered separately from other types of errors because the national focus on the security of electronic data justifies special treatment of medical information breaches. Guidelines for protecting electronic medical records should be applied equally to paper medical records.

Electronic health record (EHRs) have largely replaced obsolete paper medical charts. This replacement has produced an increased demand on physicians’ time and has compromised efficiency. In an attempt to overcome this perceived obstacle to productivity, physicians turned to medical scribes to perform the work required by EHRs. In doing so, they have introduced an uninvited participant in the physician-patient relationship and compromised patients’ confidentiality. Scribes may be a successful work around for physicians frustrated by EHRs, but patients’ confidentiality should (...) not be sacrificed in the process. (shrink)

The specific arrangements of power/knowledge that characterize nurse interactions with the electronic health record form a panopticon. As health care moves into the 21st century, sophisticated technologies like the electronic health record shape the terrain of professional possibilities. The longer it is in use, the more it is possible to excavate the inherent disciplinary function of electronic health record. A panopticon is a generalizable, replicable apparatus of power that cultivates discipline when similar behaviours are desired from a (...) group of people. This paper traces the arrangements of power/knowledge that characterize nurse interactions with the electronic health record rooted in a trauma critical care setting. Examining the apparatuses of power/knowledge enforced through panopticism in nursing makes the invisible visible. This in turn enables nurses to address the intended and unintended consequences of the electronic health record. If nurses are to effectively shape the direction of their own futures and the future of health care, nurses will need to unpack the invisible techniques of power such as the electronic health record as a panopticon. In the process of building a visible identity, contextualizing nursing knowledge to better care for patients on the one hand and understand the relationships of power that limit us on the other, nurses are neither apolitical nor powerless. Considering the dialectic of power/knowledge in the healthcare setting helps to illuminate spaces to recharacterize nursing, reveal the contributions and knowledge of nurses, and consolidate the professional power of nurses to affect meaningful change and self‐governance in the healthcare setting. (shrink)

PURPOSE—A substantial fraction of the observations made by clinicians and entered into patient records are expressed by means of negation or by using terms which contain negative qualifiers (as in “absence of pulse” or “surgical procedure not performed”). This seems at first sight to present problems for ontologies, terminologies and data repositories that adhere to a realist view and thus reject any reference to putative non-existing entities. Basic Formal Ontology (BFO) and Referent Tracking (RT) are examples of such paradigms. (...) The purpose of the research here described was to test a proposal to capture negative findings in electronic health record systems based on BFO and RT. METHODS—We analysed a series of negative findings encountered in 748 sentences taken from 41 patient charts. We classified the phenomena described in terms of the various top-level categories and relations defined in BFO, taking into account the role of negation in the corresponding descriptions. We also studied terms from SNOMED-CT containing one or other form of negation. We then explored ways to represent the described phenomena by means of the types of representational units available to realist ontologies such as BFO. RESULTS—We introduced a new family of ‘lacks’ relations into the OBO Relation Ontology. The relation lacks_part, for example, defined in terms of the positive relation part_of, holds between a particular p and a universal U when p has no instance of U as part. Since p and U both exist, assertions involving ‘lacks_part’ and its cognates meet the requirements of positivity. CONCLUSION—By expanding the OBO Relation Ontology, we were able to accommodate nearly all occurrences of negative findings in the sample studied. (shrink)

Electronic Health Records (EHRs) are organized around two kinds of statements: those reporting observations made, and those reporting acts performed. In neither case does the record involve any direct reference to what such statements are actually about. They record not: what is happening on the side of the patient, but rather: what is said about what is happening. While the need for a unique patient identifier is generally recognized, we argue that we should now move to an EHR (...) regime in which all clinically salient particulars – from the concrete disorder on the side of the patient and the body parts in which it occurs to the concrete treatments given – should be uniquely identified. This will allow us to achieve interoperability among different systems of records at the level where it really matters: in regard to what is happening in the real world. It will also allow us to keep track of particular disorders and of the effects of particular treatments in a precise and unambiguous way. We discuss the ontological and epistemological aspects of our claim and describe a scenario for implementation within EHR systems. (shrink)

The effective collection and management of personal data of rapidly migrating populations is important for ensuring adequate healthcare and monitoring of a displaced peoples’ health status. With developments in ICT data sharing capabilities, electronic personal health records (ePHRs) are increasingly replacing less transportable paper records. ePHRs offer further advantages of improving accuracy and completeness of information and seem tailored for rapidly displaced and mobile populations. Various emerging initiatives in Europe are seeking to develop migrant‐centric ePHR responses. This (...) paper highlights their importance and benefits, but also identifies a number of significant ethical, legal and social issues (ELSI) and challenges to their design and implementation, regarding (1) the kind of information that should be stored, (2) who should have access to information, and (3) potential misuse of information. These challenges need to be urgently addressed to make possible the beneficial use of ePHRs for vulnerable migrants in Europe. (shrink)

Health authorities increasingly request that general practitioners use information and communication technologies such as electronic patient records for accountability purposes. This article deals with the use of EPRs among general practitioners in Britain. It examines two ways in which GPs use the EPR for accountability purposes. One way is to generate audit reports on the basis of the information that has been entered into the record. The other is to let the computer intervene in the clinical process through (...) prompts. The article argues that GPs' ambivalence toward using the EPR makes them active in finding ways that turn the EPR into a meaningful tool for them, that is, a tool that helps them provide what they see as good care. The article's main contribution is to show how accountability and autonomy are coproduced; less professional autonomy does not follow from more requests to document one's work. Instead, new forms of autonomy are produced in the sociotechnical network that is made up by health policy and local engagements with patients and technology. (shrink)

(2013). Electronic Fences Make Good Neighbors: The Importance of Medical Records Managers to Protecting Autonomy. The American Journal of Bioethics: Vol. 13, No. 4, pp. 50-52. doi: 10.1080/15265161.2013.767965.

One of the most significant changes in modern healthcare delivery has been the evolution of the paper record to the electronic health record (EHR). In this paper we argue that the primary change has been a shift in the focus of documentation from monitoring individual patient progress to recording data pertinent to Institutional Priorities (IPs). The specific IPs to which we refer include: finance/reimbursement; risk management/legal considerations; quality improvement/safety initiatives; meeting regulatory and accreditation standards; and patient care delivery/evidence based (...) practice. Following a brief history of the transition from the paper record to the EHR, the authors discuss unintended or contested consequences resulting from this change. These changes primarily reflect changes in the organization and amount of clinician work and clinician‐patient relationships. The paper is not a research report but was informed by an institutional ethnography the aim of which was to understand how the EHR impacted clinicians and administrators in a large, urban hospital in the United States. The paper was also informed by other sources, including the philosophies of Jacques Ellul, Don Idhe, and Langdon Winner. (shrink)

Modelling nursing activities: electronic patient records and their discontents A fully integrated and operating EPR in a clinical setting is hard to find: most applications can be found in outpatient or general practice settings or in isolated hospital wards. In clinical work practice problems with the electronic patient record (EPR) are frequent. These problems are at least partially due to the models of health care work embedded in EPRs. In this paper we will argue that these problems (...) are at least partially due to the models of health care work embedded in current EPRs. We suggest that these models often contain projections of nurses’ and doctors’ work as it should be performed on the ward, rather than depicting how work is actually performed. We draw upon sociological insights to elucidate the fluid and pragmatic nature of healthcare work and give recommendations for the development of an empirically based EPR, which can support the work of nurses and other health care providers. We argue that these issues are of great importance to the nursing profession, since the EPR will help define the worksettings of the future. Since it is a tool that will impact the development of the nursing profession, nurses have and should have a stake in its development. (shrink)

From antiquity to the present the ability of clinicians to assure confidentiality has been a cornerstone of practice. Though the expectations and emphases of the various ethical codes and laws concerning confidentiality have evolved over time, it has always been the practitioner’s responsibility to observe them. The use of computers for the generation and storing of individual medical records is a significant change from our current paper-based records. That change makes the security of records a technological problem (...) generally outside the realm of physician knowledge or control. Researchers and vendors first began developing electronic health records (EHRs) in the late 1960s to 1980s. “Peripherals” were .. (shrink)

Name der Zeitschrift: Jahrbuch für Wissenschaft und Ethik Jahrgang: 20 Heft: 1 Seiten: 289-292.

BackgroundElectronic patient record (EPR) technology is a key enabler for improvements to healthcare service and management. To ensure these improvements and the means to achieve them are socially and ethically desirable, careful consideration of the ethical implications of EPRs is indicated. The purpose of this scoping review was to map the literature related to the ethics of EPR technology. The literature review was conducted to catalogue the prevalent ethical terms, to describe the associated ethical challenges and opportunities, and to identify (...) the actors involved. By doing so, it aimed to support the future development of ethics guidance in the EPR domain.MethodsTo identify journal articles debating the ethics of EPRs, Scopus, Web of Science, and PubMed academic databases were queried and yielded 123 eligible articles. The following inclusion criteria were applied: articles need to be in the English language; present normative arguments and not solely empirical research; include an abstract for software analysis; and discuss EPR technology.ResultsThe medical specialty, type of information captured and stored in EPRs, their use and functionality varied widely across the included articles. Ethical terms extracted were categorised into clusters ‘privacy’, ‘autonomy’, ‘risk/benefit’, ‘human relationships’, and ‘responsibility’. The literature shows that EPR-related ethical concerns can have both positive and negative implications, and that a wide variety of actors with rights and/or responsibilities regarding the safe and ethical adoption of the technology are involved.ConclusionsWhile there is considerable consensus in the literature regarding EPR-related ethical principles, some of the associated challenges and opportunities remain underdiscussed. For example, much of the debate is presented in a manner more in keeping with a traditional model of healthcare and fails to take account of the multidimensional ensemble of factors at play in the EPR era and the consequent need to redefine/modify ethical norms to align with a digitally-enabled health service. Similarly, the academic discussion focuses predominantly on bioethical values. However, approaches from digital ethics may also be helpful to identify and deliberate about current and emerging EPR-related ethical concerns. (shrink)

Evolving practice requires peer review of clinical ethics (CE) consultation for quality assessment and improvement. Many institutions have identified the chart note as the basis for this process, but to our knowledge, electronic health record (EHR) systems are not necessarily designed to easily include CE consultation notes. This article provides a framework for the inclusion of CE consultation notes into the formal EHR, describing a developed system in the Epic EHR that allows for the elaborated electronic notation of (...) the CE chart note. The implementation of the “meaningful use” criteria for EHR, mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, requires that health professionals meet certain standards for quality, efficiency, and safety, all of which overlap with the goals of standardization, peer review, and quality improvement within CE consultation. (shrink)

The goal of referent tracking is to create an ever-growing pool of data relating to the entities existing in concrete spatiotemporal reality. In the context of Electronic Healthcare Records (EHRs) the relevant concrete entities are not only particular patients but also their parts, diseases, therapies, lesions, and so forth, insofar as these are salient to diagnosis and treatment. Within a referent tracking system, all such entities are referred to directly and explicitly, something which cannot be achieved when familiar (...) concept-based systems are used in what is called “clinical coding”. In this paper we describe the components of a referent tracking system in an informal way and we outline the procedures that would have to be followed by healthcare personnel in using such a system. We argue that the referent tracking paradigm can be introduced with only minor – though nevertheless ontologically important – technical changes to existing EHR infrastructures, but that it will require a radically different mindset on the part of those involved in clinical coding and terminology development from that which has prevailed hitherto. (shrink)

The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing. Objective: This study examines the role of wireless, electronic, medical records and com- munications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise.

The translational research community, in general, and the Clinical and Translational Science Awards (CTSA) community, in particular, share the vision of repurposing EHRs for research that will improve the quality of clinical practice. Many members of these communities are also aware that electronic health records (EHRs) suffer limitations of data becoming poorly structured, biased, and unusable out of original context. This creates obstacles to the continuity of care, utility, quality improvement, and translational research. Analogous limitations to sharing objective (...) data in other areas of the natural sciences have been successfully overcome by developing and using common ontologies. This White Paper presents the authors’ rationale for the use of ontologies with computable semantics for the improvement of clinical data quality and EHR usability formulated for researchers with a stake in clinical and translational science and who are advocates for the use of information technology in medicine but at the same time are concerned by current major shortfalls. This White Paper outlines pitfalls, opportunities, and solutions and recommends increased investment in research and development of ontologies with computable semantics for a new generation of EHRs. (shrink)

Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was adopted recently by a team of informaticists designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in this process, (...) especially when principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and non-maleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper we show how using ethical principles can help in the design of EHRs by first, explaining how ethical principles can and should be used generally, and then by, discuss how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting further ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest. (shrink)

BackgroundThis manuscript presents a framework to guide the identification and assessment of ethical opportunities and challenges associated with electronic patient records (EPR). The framework is intended to support designers, software engineers, health service managers, and end-users to realise a responsible, robust and reliable EPR-enabled healthcare system that delivers safe, quality assured, value conscious care.MethodsDevelopment of the EPR applied ethics framework was preceded by a scoping review which mapped the literature related to the ethics of EPR technology. The underlying (...) assumption behind the framework presented in this manuscript is that ethical values can inform all stages of the EPR-lifecycle from design, through development, implementation, and practical application.ResultsThe framework is divided into two parts: context and core functions. The first part ‘context’ entails clarifying: the purpose(s) within which the EPR exists or will exist; the interested parties and their relationships; and the regulatory, codes of professional conduct and organisational policy frame of reference. Understanding the context is required before addressing the second part of the framework which focuses on EPR ‘core functions’ of data collection, data access, and digitally-enabled healthcare.ConclusionsThe primary objective of the EPR Applied Ethics Framework is to help identify and create value and benefits rather than to merely prevent risks. It should therefore be used to steer an EPR project to success rather than be seen as a set of inhibitory rules. The framework is adaptable to a wide range of EPR categories and can cater for new and evolving EPR-enabled healthcare priorities. It is therefore an iterative tool that should be revisited as new EPR-related state-of-affairs, capabilities or activities emerge. (shrink)

In the last two decades we have witnessed considerable efforts directed towards making electronic healthcare records comparable and interoperable through advances in record architectures and (bio)medical terminologies and coding systems. Deep semantic issues in general, and ontology in particular, have received some interest from the research communities. However, with the exception of work on so-called ‘controlled vocabularies’, ontology has thus far played little role in work on standardization. The prime focus has been rather the rapid population of terminologies (...) at the level of fine detail. In this paper, we argue that more efforts are needed on the side of both research and standardization to ensure that the coding systems used in electronic healthcare records enjoy a semantics that is coherent with the semantics of the record. We propose realist ontology as a method to bring about this coherence by means of a robust system of top-level ontological categories. (shrink)

Despite the recent advances in information and communication technology that have increased our ability to store and circulate information, the task remains of ensuring that the right sorts of information reach the right sorts of people. In what follows we defend the thesis that efforts to develop efficient means for sharing information across healthcare systems and organizations would benefit from a careful analysis of human action in healthcare organizations, and that the communication of healthcare information and knowledge needs to rest (...) on a sound ontology of social interaction. We illustrate this thesis in relation to the HL7 RIM, which is one centrally important tool for communication in the healthcare domain. (shrink)

ZusammenfassungIn einem Modellprojekt soll durch die Einführung einer persönlichen, einrichtungsübergreifenden, elektronischen Patientenakte nicht nur die Behandlungskontinuität verbessert, sondern auch das Recht auf informationelle Selbstbestimmung dahingehend realisiert werden, dass jeder Patient zum Administrator einer Datencloud gemacht wird, die alle seine Gesundheitsdaten enthält. Eine systematische Literaturrecherche zum Thema „elektronische Patientenakten “ soll mögliche ethische Herausforderungen in Verbindung mit der oben genannten PEPA antizipieren. Von initial 2487 Publikationen wurden 51 Publikationen ausgewertet: 30 empirische Studien, 10 medizinethische Analysen und 11 Meinungspapiere. In den empirischen (...) Studien wurden als erste Effekte einer EPA vor allem eine vollständigere medizinische Aktenlage beschrieben. Mit der Einsichtsmöglichkeit für den Patienten in die EPA konnten zusätzlich ein besseres Krankheitsverständnis und damit erhöhte Compliance des Patienten nachgewiesen werden. Eine Verbesserung der Behandlungsqualität wurde auf die Fehlervermeidung durch Patienteneinsicht, effektivere Nutzung der Arzt-Patienten-Besuche und das verbesserte Verständnis für das Therapiekonzept zurückgeführt. Ebenfalls wurde in den Studien eine Stärkung des Vertrauensverhältnisses von Arzt und Patient beschrieben. Bedenken gab es im Vorfeld vieler Studien hinsichtlich des Datenschutzes, eines möglichen Verlustes der persönlichen Arzt-Patienten-Beziehung und einer potentiellen Überforderung des Patienten. In der Beurteilung der EPA spielte die Abwägung zwischen ärztlicher Fürsorge und Patientenautonomie eine große Rolle. Die von medizinethischer Seite geäußerten Bedenken bezüglich eines Vertrauensverlustes oder einer Störung des Arzt-Patienten-Verhältnisses konnten in den empirischen Studien nicht bestätigt werden. Die befürchteten Risiken im Datenschutz wurden von den Betroffenen zugunsten des potentiellen Nutzens einer EPA abgewogen. Unter Wahrung des Datenschutzes hat daher die PEPA das Potential, durch die Mitbeteiligung des Patienten das Arzt-Patienten-Verhältnis positiv zu beeinflussen. Die spezifischen ethischen Herausforderungen, die mit der Co-Verwaltung der PEPA einhergehen, werden im Modellprojekt untersucht. (shrink)

National electronic health record initiatives are in progress in many countries around the world but the debate about the ethical issues and how they are to be addressed remains overshadowed by other issues. The discourse to which all others are answerable is a technical discourse, even where matters of privacy and consent are concerned. Yet a focus on technical issues and a failure to think about ethics are cited as factors in the failure of the UK health record system. (...) In this paper, while the prime concern is the Australian Personally Controlled Electronic Health Record (PCEHR), the discussion is relevant to and informed by the international context. The authors draw attention to ethical and conceptual issues that have implications for the success or failure of electronic health records systems. Important ethical issues to consider as Australia moves towards a PCEHR system include: issues of equity that arise in the context of personal control, who benefits and who should pay, what are the legitimate uses of PCEHRs, and how we should implement privacy. The authors identify specific questions that need addressing. (shrink)

Referent Tracking (RT) advocates the use of instance unique identifiers to refer to the entities comprising the subject matter of patient health records. RT promises many benefits to those who use health record data to improve patient care. To further the adoption of the paradigm we provide an illustration of how data from an EHR application needs to be decomposed in order to make it accord with the tenets of RT. We describe the ontological principles on which this decomposition (...) is based in order to allow integration efforts to be applied in similar ways to other EHR applications. We find that an ordinary statement from an EHR contains a surprising amount of “hidden” data that are only revealed by its decomposition according to these principles. (shrink)

Use of electronic health records within clinical encounters is increasingly pervasive. The digital record allows for data storage and sharing to facilitate patient care, billing, research, patient communication and quality-of-care improvement—all at once. However, this multifunctionality is also one of the main reasons care providers struggle with the EHR. These problems have often been described but are rarely approached from a philosophical point of view. We argue that a postphenomenological case study of the EHR could lead to more (...) in-depth insights. We will focus on two concepts—transparency and multistability—and translate them to the specific situation of the EHR. Transparency is closely related to an embodiment relation in which the user becomes less aware of the technology: it fades into the background, becoming a means of experience. A second key concept is that of multistability, referring to how a technology can serve multiple purposes or can have different meanings in different contexts. The EHR in this sense is multistable by design. Future EHR design could incorporate multistable information differently, allowing the provider to focus on patient care when interacting with the EHR. Moreover we argue that the use of the EHR in the daily workflow should become more transparent, while awareness of the computer in the specific context of the patient-provider relationship should increase. (shrink)

Often a physician’s first introduction to a patient is not a physical encounter but a review of their chart. A glaring “violence risk” flag in an Electronic Medical Record (EMR) is often noticeable...