1. The Culture of Healthcare
Ethics and Professionalism
Welcome to The Culture of Healthcare, Ethics and Professionalism. This is Lecture (d).
The component, The Culture of Healthcare, addresses job expectations in healthcare settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
Lecture d
This material (Comp2_Unit8d) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Ethics and Professionalism Learning Objectives
Provide an orientation to ideas about medical ethics and professionalism (Lecture a)
Explore the relationships among ethical ideals, professionalism, and legal duties (Lecture a, b)
Apply the general principles of ethics and professionalism to specific topics (Lecture c, d)
Examine ethical issues in health informatics (Lecture d)
The objectives for Ethics and Professionalism are to:
Provide an orientation to ideas about medical ethics and professionalism
Explore the relationships among ethical ideals, professionalism, and legal duties
Apply the general principles of ethics and professionalism to specific topics
Examine ethical issues in health informatics
Health IT Workforce Curriculum Version 3.0/Spring 2012
Ethics and Professionalism Ethical Issues in Health Informatics
Lecture d

3. Ethical Issues in Health Informatics
Sources of ethical standards in health informatics
Professionalism
Representing credentials
Privacy, confidentiality, and security
Respect for patients and co-workers
Responding to unethical practices
This lecture discusses ethical issues in health informatics. Just as in the medical field as a whole, health informatics professionals face numerous, and sometimes difficult, ethical issues.
After a brief discussion of professionalism, this lecture examines four ethical duties of health informatics professionals: the duty to represent credentials accurately; the duty to protect patient privacy, including the related ideas of confidentiality and security; the duty to respect patients and co-workers; and the duty to respond to unethical practices by others.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Ethics and Professionalism Ethical Issues in Health Informatics
Lecture d

4. Sources of Ethical and Professional Standards in Health Informatics
Codes of ethics
American Health Information Management Association (AHIMA)
American Medical Informatics Association (AMIA)
International Medical Informatics Association (IMIA)
Federal and state governments
Agency for Healthcare Research and Quality (AHRQ) National Resource Center for Health Information Technology
Office of the National Coordinator for Health IT (ONC)
As in other healthcare fields, the ethical and professional standards of the health informatics profession come from a variety of sources. Several voluntary professional organizations have developed codes of ethics, including the American Health Information Management Association, the American Medical Informatics Association, and the International Medical Informatics Association.
Arms of the federal government, such as the Office of the National Coordinator for Health Information Technology, have added to the body of knowledge about appropriate practices and are sources of standards of ethics and professionalism.
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Lecture d

5. Ethics and Law Interact
Privacy and security rules in the Health Insurance Portability and Accountability Act (HIPAA)
Health Information Technology for Economic and Clinical Health Act (HITECH)
Lawsuits and case law about failure to meet minimum professional standards
There is a back-and-forth interaction between the ethical ideals, professional standards, and legal requirements that apply to health informatics. The privacy and security rules contained in HIPAA [HIP-uh], the Health Insurance Portability and Accountability Act, are part of a law but are also very important sources of professional standards. The law known as the Health Information Technology for Economic and Clinical Health Act, or HITECH [high-TEK], widens the scope of privacy and security protections available under HIPAA and increases the potential legal liability for non-compliance.
Health informatics law is outside the scope of this lecture. However, it is important to remember that the law sets standards that may overlap, exceed, or even conflict with ethical duties.
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6. Ethics and Professionalism Ethical Issues in Health Informatics
Behavior in accordance with generally accepted ideas of appropriate conduct within a specific profession
In health informatics, it includes:
Knowledge of ethical requirements and ideals
Maintenance of professional skills
One of the ethical standards for people in health informatics is professionalism. The term professionalism refers to behaving in accordance with the generally accepted ideas of appropriate conduct within a specific profession.
Obviously, it is first necessary to know what the accepted standards of behavior are. In health informatics, one example is to become familiar with the ideas expressed in the ethical codes written by health informatics organizations. Another component of professionalism is to maintain the skills necessary to perform all work-related duties, such as taking continuing education classes.
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Lecture d

7. Conflicts of Interest: When Duties and Motives Clash
Another aspect of professionalism is to avoid or report conflicts of interest. To briefly review the information covered in a previous lecture, conflict of interest arises when a person is faced with a situation in which a primary interest conflicts with a secondary motivation. Primary duties include ethical and legal requirements, such as the obligation to keep patient information private. Secondary motivations are personal interests such as the opportunity for financial gain.
8.10 Figure: Conflicts of interest (CC BY-NC-SA 3.0, 2012).
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Lecture d

8. Example of a Conflict of Interest
Patients get medical appointments in order of listing in database
Close friend is far down, asks to be moved up
Primary duty: treat all patients fairly
Secondary motivation: friendship
Conflicts of interest cannot always be avoided
If not, they should be disclosed to supervisor or other appropriate person
For example, imagine a situation in which patients are supposed to receive medical appointments in the order in which their information was placed in a database. Imagine that a close friend is very far down on the list and asks to be moved up on the list. In this situation the primary duty is to treat all patients on the list fairly. However, the personal motivation of friendship provides a strong emotional pull in the direction of making an exception for the friend.
Any potential conflict of interest should be disclosed to appropriate parties. In this example, it might be appropriate to disclose this conflict to a supervisor and assure them that the proper protocol will be observed.
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Lecture d

9. Represent Credentials Accurately
Report professional qualifications accurately, including:
Abilities
Training
Certification
Relevant professional experience
Correct any inaccuracies regarding credentials
Report only continuing education units actually earned, and correct any inaccuracies
The next section of this lecture examines a few of the ethical standards from the ethical codes of national and international health informatics organizations. In the Code of Ethics of the American Health Information Management Association, one of the 11 ethical principles is the obligation to accurately represent one’s credentials. Similarly, the Code of Ethics of the International Medical Informatics Association says, “Except in emergencies, health informatics professionals should only provide services in their areas of competence; however, they should always be honest and forthright about their education, experience or training.”
For example, informatics professionals should not “pad” their resumes by overstating their education, experience, or capabilities. In addition, they should correct any inaccuracies that may occur. These are duties owed to employers, patients, and the general public.
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10. Ethics and Professionalism Ethical Issues in Health Informatics
Privacy
“A health information management professional shall: advocate, uphold, and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information” — AHIMA Code of Ethics
“All persons have a fundamental right to privacy, and hence to control over the collection, storage, access, use, communication, manipulation and disposition of data about themselves” — IMIA Code of Ethics
As with many topics related to ethics, there are many different definitions of privacy. For the purpose of this lecture, privacy is defined as the patient’s right to control how their health information is used, and when and whether it is disclosed.
Both the American Health Information Management Association and International Medical Informatics Association place privacy in the number one position on their lists of guiding ethical principles for health informatics professionals.
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Lecture d

11. Privacy = Confidentiality + Security
Confidentiality = do not improperly disclose information
Security = safeguard patient information from improper access by others
Privacy includes:
Advocating for laws respecting patient privacy
Promoting these values among colleagues
According to several codes of ethics, the principle of respect for privacy means that health informatics professionals must keep patients’ information both confidential and secure. Confidentiality means the informatics professional will not improperly disclose the information. Security means the professional will take appropriate measures to protect the information from being inappropriately accessed by others.
In addition to protecting patient information, the duty to respect privacy includes an obligation to advocate for laws about protecting patients’ health information. It also includes a duty to promote the values of confidentiality and security to colleagues.
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Lecture d

12. Ethics and Professionalism Ethical Issues in Health Informatics
Respect for Patients, Employers, and Co-workers (AHIMA Code of Ethics. 2011)
Respect the inherent dignity and worth of every person
Treat each person in a respectful fashion, being mindful of individual differences and cultural and ethnic diversity
Promote the value of self-determination for each individual
Value all kinds and classes of people equitably, deal effectively with all races, cultures, disabilities, ages and genders
Ensure all voices are listened to and respected
The Code of Ethics of the American Health Information Management Association makes a strong statement about the duties owed to others. It states that a health informatics professional should “Respect the inherent dignity and worth of every person.”
The Code provides guidelines to help clarify how this lofty ideal can be put into action. Its guidelines state that all people should be treated respectfully and equitably. The duty to respect the dignity and worth of each person includes many obligations towards patients, co-workers, and employers.
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13. Duties Owed to Patients: The Basics Apply
The duties of a health informatics professional to patients are based on the same four core ethical principles that apply to all healthcare professionals: respect for autonomy, beneficence [buh-NIFF-fuh-sense], non-maleficence [non-muh-LIFF-fuh-sense], and justice. These concepts are explained in detail in a previous lecture.
8.11 Figure: Duties to patients (CC BY-NC-SA 3.0, 2012).
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Lecture d

14. Ethics and Professionalism Ethical Issues in Health Informatics
Duties Owed to Patients: The Basics Apply (continued) (IMIA Code of Ethics, 2011)
Autonomy: “All persons have a fundamental right to self-determination”
Justice: “All persons are equal as persons and have a right to be treated accordingly”
Beneficence: “All persons have a duty to advance the good of others where the nature of this good is in keeping with the fundamental and ethically defensible values of the affected party”
Non-maleficence: “All persons have a duty to prevent harm to other persons insofar as it lies within their power to do so without undue harm to themselves”
This slide explains how the four general principles are stated in the Code of Ethics of the International Medical Informatics Association.
The principle of autonomy implies that all people have a fundamental right to self-determination.
According to the principle of justice, all people are equal and have a right to be treated accordingly.
The principle of beneficence means that all people have a duty to advance the good of others, as long as the nature of that good is in keeping with ethically defensible values.
The flip side of beneficence is non-maleficence, the principle that all people have a duty to prevent harm to others, insofar as they can do so without undue harm to themselves.
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Lecture d

15. Duties Owed to Patients (continued)
Recognize that patients have a right to know about the existence of electronic records and how they will be used
Ensure that patient data is maintained in a safe, reliable manner
Never use patients’ data for outside purposes
Treat the data of all patients with equal respect
The Code of Ethics of the American Medical Informatics Association says patients have the right to know about the existence of electronic records containing their personal medical data. It says informatics professionals should not mislead patients about how these data are used. They should truthfully answer all patient questions about their rights to review and revise their own medical data. In addition, informatics professionals should be helpful when a patient wishes to exercise those rights.
Informatics professionals should ensure that medical data are maintained in a secure, reliable, manner. Further, the Code says medical data should never be used for purposes “outside the stated purposes, goals, or intents of the organization responsible for these data.” In addition, the data of all patients should be treated with equal care, respect, and fairness. These are just a few examples of the duties owed to patients.
— AMIA Code of Ethics
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Lecture d

16. Duties Owed to Employers (IMIA Code of Ethics, 2011)
Competence, diligence, integrity, and loyalty
Best data security measures
Highest possible qualitative standards of data collection, storage, retrieval, processing, accessing, communication, and utilization
Appropriate systems for evaluating the technical, legal, and ethical acceptability of the data
The Code of Ethics of the International Medical Informatics Association lists nine general duties that informatics professionals owe to their employers. Generally, these include competence, diligence, integrity, and loyalty.
In addition, health informatics professionals must ensure that all processes are performed to the highest possible standards, and that all requirements and standards regarding security are met. The Code also says that informatics professionals should have systems for reviewing their processes and practices to make sure they are current and effective.
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17. Duties Owed to Healthcare Professionals (IMIA Code of Ethics, 2011)
Provide informatics services necessary for healthcare professionals to carry out their obligations
Provide timely and secure access to relevant electronic records
Ensure the usability, integrity, and highest possible technical quality of the records
In many workplaces, informatics professionals work with doctors, nurses, and other healthcare providers who are their co-workers, not their employers. According to the Code of Ethics of the International Medical Informatics Association, healthcare providers have a right to depend on the technological skills of health informatics professionals to help them meet their own professional obligations to patients. Therefore, it is an ethical duty for informatics professionals to assist healthcare providers “insofar as this is compatible with the [health informatics professionals’] primary duty towards the subjects of the electronic records.”
The Code lists practical examples of these obligations. They include ensuring that healthcare providers have timely and secure access to useable, high-quality electronic records.
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Lecture d

18. Responding to Unethical Practices
“Health informatics professionals will refrain from impugning the reputation of colleagues but will report to the appropriate authority any unprofessional conduct by a colleague” (IMIA Code of Ethics, 2011)
“A health information professional shall take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues” (AHIMA Code of Ethics, 2011)
According to the Codes of Ethics of the International Medical Informatics Association and the American Health Information Management Association, it is not enough to simply refrain from unethical behavior. Health informatics professionals have ethical duties to discourage others from unethical behavior, to correct ethical problems when they occur, and to expose the unethical practices of others.
Health IT Workforce Curriculum Version 3.0/Spring 2012
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Lecture d

19. Ethics and Professionalism Ethical Issues in Health Informatics
Whistleblowing
Duty to report can conflict with feelings of loyalty
May result in retaliation
Snubs by co-workers
Loss of promotions or raises
Physical assault
Laws may protect whistleblowers
People who report unethical or illegal practices are sometimes called whistleblowers. As discussed in more detail in a previous lecture, the obligation to report unethical practices can result in some challenging situations. The duty to report a co-worker’s unethical behavior can result in mental or emotional conflicts about difficult issues such as loyalty. It can result in retaliation, ranging from getting the cold shoulder from co-workers to loss of promotions or raises, or even physical assault.
Many laws provide protection for people who report unethical practices. However, they apply only under certain circumstances, and proving retaliation may be difficult.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Ethics and Professionalism Ethical Issues in Health Informatics
Lecture d

20. Ethics and Professionalism Summary – Lecture d
Health informatics professionals have general standards of ethical behavior and professionalism
Major sources of standards come from codes of ethics written by health informatics professional societies
There are four ethical duties of health informatics professionals:
Represent credentials accurately
Protect patient privacy, including confidentiality and security
Respect patients and co-workers
Respond to unethical practices by others
This concludes Lecture (d) of Ethics and Professionalism.
In summary, the general standards of ethical behavior and professionalism that apply to healthcare providers, such as doctors and nurses, also apply to health informatics. Major sources of these standards are the codes of ethics written by health informatics professional societies, such as the American Health Information Management Association, the American Medical Informatics Association, and the International Medical Informatics Association. These standards are supplemented by federal agencies such as the Office of the National Coordinator for Health Information Technology.
The four ethical duties of health informatics professionals are the duty to represent credentials accurately; the duty to protect patient privacy, including the related ideas of confidentiality and security; the duty to respect patients and co-workers; and the duty to respond to unethical practices by others.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Ethics and Professionalism Ethical Issues in Health Informatics
Lecture d

21. Ethics and Professionalism Summary
Professionalism requires that people act in accordance with the standards of their profession
Healthcare professionals must meet both ethical and legal standards
Informed consent, end-of-life issues, conflicts of interest, healthcare disparities, and conscientious objection are among the many difficult ethical issues faced by healthcare professionals
Codes of ethics provide guidance for health informatics professionals
This also concludes Ethics and Professionalism. In summary, professionalism requires a person to maintain their work-related skills and adhere to ethical and legal standards. However, behaving ethically as an individual is not enough. A professional must also foster an ethical work environment and correct the unethical practices of others. The healthcare field as a whole presents many difficult ethical dilemmas, including the need for informed consent, end-of-life issues, conflicts of interest, healthcare disparities, and conscientious objection.
The general standards of ethical behavior and professionalism that apply to healthcare providers, such as doctors and nurses, also apply to health informatics. The standards that apply specifically to the health informatics profession come from a variety of sources. Major sources of these standards are the codes of ethics written by health informatics professional societies. According to these codes, informatics professionals are expected to demonstrate competence, diligence, integrity, and loyalty. They also have an ethical duty to not only refrain from unethical behavior, but to discourage others from unethical behavior, to correct ethical problems when they occur, and to expose the unethical practices of others.
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22. Ethics and Professionalism References – Lecture d
American Health Information Management Association [Internet]. Undated [cited 2011 Dec 29]. American Health Information Management Association Code of Ethics [1 page]. Available from:
American Medical Informatics Association [Internet]. Undated draft [cited 2011 Dec 29]. Biomedical informatics core competencies [1 page]. Available from:
Ethics Resource Center [Internet]. December 2010 [cited 2011 Dec 30]. Blowing the whistle on workplace misconduct [16 pages]. Available from: .
Hurdle JF, Adams S, Brokel J, et al. A code of professional ethical conduct for AMIA. J Am Med Inform Assoc. 2007;14(4):
Institute of Medicine [Internet] [cited 2011 Dec 29]. Conflict of Interest in Medical Research, Education, and Practice [436 pages]. Available from:
Institute of Medicine [Internet]. Prepublication [cited 2011 Dec 30]. Health IT and Patient Safety: Building Safer Systems for Better Care [197 pages]. Available from:
International Medical Informatics Association [Internet]. Undated [cited 2011 Dec 29]. The IMIA Code of Ethics for Health Information Professionals [10 pages]. Available from:
References slide. No audio.
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23. Ethics and Professionalism References – Lecture d (continued)
Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services [Internet]. October 2011 [cited 2011 Dec 29]. About ONC [1 page]. Available from:
Samuel HW, Zaiane OR, Sobsey D. Towards a definition of health informatics ethics. In: Proceedings of the First ACM International Health Informatics Symposium. New York: Association for Computing Machinery, Available from:
Charts, Tables, Figures
8.10 Figure: Conflicts of interest (CC BY-NC-SA 3.0, 2012).
8.11 Figure: Duties to patients (CC BY-NC-SA 3.0, 2012).
References slide. No audio.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Ethics and Professionalism Ethical Issues in Health Informatics
Lecture d