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Assignment Ethical Dimensions of Meaningful Use

Assignment: Ethical Dimensions of Meaningful Use

Ethical Dimensions of Meaningful Use and Chapter Work Products

Your Lesson 1 Assignment has five parts:

1. Please read the article titled Ethical Dimensions of Meaningful Use Requirements for Electronic Health Records at this link: http://journalofethics.ama-assn.org/2011/03/pfor1-1103.html

Summarize the important points you took away from that article in a well-written narrative (250-300 words) and submit to your instructor for evaluation.

2. Please produce and save the patient logs for the three patients you created in Chapter 3 (see pages 39-41 for detailed instructions).

3. Please produce and save work you created in Chapter 5 (see pages 65-66 for detailed instructions). Make sure you complete the Self-Assessment to make very certain your work is error-free before submitting. Your instructor will also be able to view your work online.

4. Please produce and save all three schedule prints (for your location, for Dr. Stimson, and for Dr. Carver) you created in Chapter 6. See pages 103-106 for detailed instructions.

5. Please produce and save the clinical notes for the two patients you registered in Chapter 7. See page 128 for detailed instructions.

Identifying and Addressing Ethical Issues with Use of Electronic Health Records

Healthcare delivery in the United States (U.S.) is changing at a rapid pace to keep up with the ever-growing population health needs and for management of chronic diseases (Healthy Aging Team, 2017). With the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 (U.S. Department of Health and Human Services, 2012), the United States, as of 2017, has achieved a 95% saturation with electronic health records (EHRs) as a means to document healthcare delivery in acute care hospitals and guide healthcare delivery clinical decision making (Office of National Coordinator for Health Information Technology, 2017). Approximately 60% of U.S. office-based physicians have an EHR implemented and in use.

…in many respects, care has improved with use of technologies…Collectively, these trends impact nurses nationwide across all care settings. Studies have indicated that, in many respects, care has improved with use of technologies and, when meaningful use of EHRs is fully achieved and experienced by nurses, they are much more likely to be satisfied with the EHR (McBride, Tietze, Hanley, & Thomas, 2017). Evidence is mounting that these same systems are also resulting in unintended consequences with patient safety implications, potentially contributing to provider moral distress (Henry, Pylypchuk, Searcy, & Patel, 2016). Clinical teams often confront usability challenges that present ethical issues and require ethical decision-making models to support clinicians with appropriate action on behalf of safe and effective clinical care.

Clinical teams often confront usability challenges that present ethical issues…The purpose of this article is to identify and address ethical issues raised by nurses in use of EHRs. We provide a case scenario with application of the Four Component Model (FCM) (Rest, 1986). To do this, a clinical case study will be presented, along with discussion of nurse experiences using the EHRs in a recent study (McBride, Tietze, Hanley, & Thomas, 2015). Then, recommendations and a call to action are made based on the FCM in light of nursing practice standards, ethical issues, and where applicable legal issues.

…formulaic alerts can present challenges to clinical decision making…One strength associated with certified EHRs under the HITECH Act of 2009 for supporting patient safety and quality is that evidenced-based protocols can be reinforced by using clinical decision support (CDS). CDS is designed to trigger, or alert, the clinical team with the right information, through the right channels, to the right person, at the right time, for the right patient, via the correct route of the EHR or supporting technologies (Osheroff et al., 2012). These same formulaic alerts can present challenges to clinical decision making for clinical teams working with an actual patient, raising practical and ethical considerations.

When examining ethical issues and applying frameworks to analyze a situation, clinical scenarios often help to ground discussions of problems in the day-to-day clinical care that commonly occur in healthcare delivery. The following case presents a scenario for applying a framework to address ethical concerns that nurses have raised regarding the function of some EHRs.

Case Scenario

She suspects that the afebrile patient does not have sepsis, but instead has an exacerbation of HF with possible pulmonary edema…Nancy has worked in a busy community hospital emergency department (ED) for over ten years. She is caring for a patient that presents to the ED with the following:

  • sepsis suspected due to possible pneumonia
  • oxygen saturation 88% on 4 liters of O2 via nasal cannula
  • respiratory rate of 30
  • heart rate of 110

These symptoms trigger the EHR CDS alert for sepsis because the patient scored high on the hospital sepsis screening tool built within the EHR. The CDS fires alerts that prompt the ordering physician to fluid resuscitate the patient according to the Center for Disease Control guidelines for suspected sepsis. Nancy recognizes that not only does this patient have symptoms that could be evolving sepsis, but the EHR indicates the patient has previously been admitted for fluid overload from heart failure (HF). She suspects that the afebrile patient does not have sepsis, but instead has an exacerbation of HF with possible pulmonary edema because the patient also exhibits 2+ pitting edema and crackles in both lung bases.

The ED physician follows the CDS sepsis alerts that call for fluid resuscitation.The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. Nancy questions the doctor order for aggressive fluid bolus and relates her concern that the patient is not septic. She points out the history of HF, which creates a risk for fluid overload with the bolus. The physician agrees with the nurse but states, “just drip it in slow, otherwise if we don’t follow protocol we may fall out of the sepsis quality metric for the hospital. I don’t want to send this patient to the ICU and have it later determined to be a sepsis case that we didn’t follow protocol on!”

[Nancy] feels very distressed but hopes for the best outcome for this patient.No order for a slow drip was noted in the EHR, with only a verbal instruction on a busy ED shift for a patient ready for transfer to the ICU. Nancy questions the appropriateness of the physician orders, but follows physician instructions. She feels very distressed but hopes for the best outcome for this patient. She subsequently reports the request by the physician to drip slowly in a verbal handoff to the ICU nurse who receives the patient. The ICU nurse, recognizing that the drip does not follow the EHR recorded order, opens up the drip according to the computer provider order entry (CPOE). The patient has respiratory arrest. The patient requires intubation due to flash pulmonary edema with a subsequent diagnosis of acute onset of exacerbated fluid overload, secondary to rapid administration of intravenous (IV) fluid bolus and complication of HF. The attending intensivist on duty determines that the patient does not have sepsis.

This case presents a scenario happening across the nation in terms of EHR triggered protocols that capture electronic quality measures, often tied to value-based purchasing payer models upon which the organization will be penalized in the event measures are not met. This case study illustrates evolving guidelines that require clinical teams to use critical thinking skills when presented with CDS or information within the EHR that is not aligned with the clinical judgment of the entire clinical team. Further, this case offers several ethical considerations for examination. The scenario also reinforces nurses’ statements as reported in 2015 via the Texas Nurses Association-Texas Organization of Nurse Executives (TNA-TONE) statewide study on EHRs (McBride et al., 2015). For example, the following was one of 352 statements by nurses about EHR experiences:

Yes, the documentation of “quality standards” has greatly improved, but patient care and patient safety has not. In fact nurses have to enter false information sometimes and work around the system (I use vendor X, Y and Z) and all have similar issues. I know first-hand of 2 sentinel events caused by the systems (X and Y). Also systems audits are being used to evaluate and discipline nurses; this is a big ethical issue as nurses are charting stuff for the wrong reasons/……..creating a conflict of interest.

This case scenario can be examined in terms of the overall context of ethical implications in use of the EHR. We can also consider the distress that can occur when protocols/guidelines; clinical decision support systems; nurse-patient relationship; and clinical communications between and among teams conflict with a nurse’s code of ethics.

Assignment Ethical Dimensions of Meaningful Use

Assignment Ethical Dimensions of Meaningful Use

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Study of Nurse Experiences with the EHR

As a result of the HITECH Act in 2009, the TNA Board of Directors formed a Health Information Technology advisory committee. This committee was to evaluate the changing health technology environment and make recommendations to the TNA Board regarding steps needed to prepare Texas nurses for the rapid uptake of technology in healthcare settings required by this legislation. The TNA Board joined with the Texas Organization of Nurse Executives (TONE) to create a statewide partnership with nursing leaders to address the impact of health information technology (HIT) on nursing in the state of Texas.

The TNA-TONE HIT committee was charged with examining how Texas nurses were impacted by newly implemented EHRs across the state and to establish baseline measures of nurse satisfaction to inform evidence-based improvement strategies. A statewide study was initiated to evaluate nurse perceptions about clinical information systems such as EHRs.

… analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas…Quantitative results from the statewide study indicated that nurses were 84% more likely to be satisfied when they reported high scores related to a meaningful use maturity sensitivity index (MUMSI). The MUMSI allowed for analysis that addressed differing levels of functional status, or maturity of the given EHR using the meaningful use (MU) measures as a proxy for maturity (McBride et al., 2017). However, analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas (please note that we are using the terms “moral” and “ethical” interchangeably in accordance with the current literature). We believe the ethical issues, in particular, warrant further exploration and require models of decision making to support clinical interprofessional teams in appropriate decision-making and subsequent action.

In the Texas-based statewide study (McBride et al., 2015), researchers elicited additional information to learn about experiences of nurses using EHRs with this open-ended statement: “We are interested in your feedback and anything we might not have covered, please provide any additional information you care to provide.” Just over 30% (352 of 1,157 participants) provided written comments about their experiences.

A thematic content analysis of the narrative responses to the open text question was used to analyze the data. Texts were organized in a spreadsheet and reviewed systematically by two qualitative researchers from the TNA/TONE committee research subgroup to identify key concepts. The text narrative responses were then reorganized according to concepts and summarized into categorical statements. Further immersion and analysis of the categories by two researchers with informatics expertise resulted in a synthesis of comments within the categories that revealed several primary themes. These are noted in Figure 1.

A conceptual model that reflects the overall common concepts detected in the thematic analysis was developed by the research group and is also noted in Figure 1. Note that “Patient Safety and Quality” is a major theme, with a minor theme “documentation/legality.” This suggested that practice challenges associated with patient safety and quality were experienced. We learned that these were reflected, among other ways, in the EHR-based documentation that varied from established interprofessional practice standards. Although the case study and the Texas nurses’ comments reflected ethical issues raised by nurses, there are significant implications for the entire care team given the EHR is the primary means of interprofessional communication.

Figure 1. Major and minor themes related to qualitative study comments.

Assignment: Ethical Dimensions of Meaningful Use

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A sampling of these comments is provided by categories in Table 1. They are grouped by category of content.

Table 1. Comments by Nurses about their EHR Experience

Category Comment
Training I have almost no training on the “System.” I have to fumble around to do anything on this “System” and it is purely an accident when I do find what I need.
Documentation System was not designed by the people who would use it. It does not capture the data required by the state to successfully use it. We are unable to see any notes/assessments that we did not personally input. Very frustrating because we constantly have to do double work.

Sometimes the canned responses to questions do not have the appropriate answer listed as an option, and the only way to complete the documentation is to go to another menu and enter a nurse’s note. Our preop department uses entries in both the nursing module and the OR module, which necessitates constantly switching from one menu to another – time consuming and inefficient.

The “copy/paste” function has made it easier for providers to not write new original assessments. Because most of the notes are copy and pasted, there are many discrepancies (on one line, the patient is intubated; on the next line of the same patient, the patient is on nasal cannula). It’s made the notes semi-worthless.

This system has quadrupled our workload. It is not accurate and orders tend to disappear. The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. This system is difficult to view orders and communicate with others. Things do not work well. It takes several hours to get thru discharges due to links that do not work. With the ER after two weeks on the program, it developed an application error that would not let nurses go back to add information while the patient is still active and document is active.

Equipment Our computers at times freeze inside the room. During am med pass, it is so stressful finding a good computer that does not freeze. Sometimes I have to go through 3-5 computers before finding one that works.
Critical Thinking Sometimes I feel that the barcode scanning system for medication administration hinders critical thinking and prevents truly looking at what you are giving the patient.

Four Component Model

The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action…The case scenario above provides an opportunity to explore a holistic framework, the Four Component Model (Rest, 1986), to identify and address ethical issues in nursing practice. The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action: sensitivity, judgment, motivation, and action (Rest, 1986Robichaux, 2012Robichaux, 2017Rushton & Penticuff, 2007).

Ethical Sensitivity
Ethical sensitivity is described as our ability to recognize an ethical problem, the moral implications of our decisions, and how our actions affect other people (Milliken, 2016). Its development depends on an understanding of the ethical nature of the role as an obligation of the nursing profession (Milliken & Grace, 2017). In the case scenario, Nancy recognized that adhering to the EHR-triggered CDS guideline might result in a poor outcome. She may have also been aware of her accountability in the situation as stated in the ANA Code of Ethics for Nurses with Interpretive Statements, “Systems and technologies that assist in clinical practice are adjunct to, not replacements for, the nurse’s knowledge and skill” (American Nurses Association [ANA], 2015, p.16; hereafter referred to as Code of Ethics). Having practiced in the ED for ten years, Nancy may be respected by her nursing peers and physician colleagues and may question how her actions could potentially affect those professional relationships.

Ethical Judgment
Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty.The second component of the FCM is ethical judgment or decision-making, a deliberative process reflecting knowledge of ethical principles, theories, and codes. There are several models (see Table 2); most have elements that outline an approach to reaching a decision through identifying facts and considering specific questions related to ethical principles and/or virtue ethics and care ethics. Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty (Grace, 2014Milliken & Grace, 2017Robichaux, 2017). Recognizing the potential harm of following the sepsis guidelines in a patient with suspected pulmonary edema, Nancy decides to share her concerns with the physician.

Table 2. Ethical Judgment/Decision-making Models

Internet Sources for Ethical Judgment/Decision-Making Models
The University of Washington School of Medicine. (2014). A case-based approach to ethical decision-making. Retrieved from https://depts.washington.edu/bioethx/tools/4boxes.html
Brown University. (2013). A framework for making ethical decisions. Retrieved from https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions
Santa Clara University Markula Center for Applied Ethics. (2017). Ethical decision making. Retrieved from https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/

Ethical Motivation
All nurses want to be ethical and live in a manner consistent with their personal and professional values. Although they may recognize an ethical issue and be aware of their role-associated obligations, personal and/or institutional barriers may impede their motivation to act. The third component in the FCM, ethical motivation is the bridge between decision-making and action (Robichaux, 2017).

Competing personal values… can impede motivation and action.Competing personal values such as protecting one’s position or reputation can impede motivation and action. “Persevering to do the right thing” (Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014, p. 14) can also be hampered by institutional barriers. Lack of supervisory support, fear of reprisal, and hierarchal decision-making may silence nurses’ moral voices (Pavlish, Hellyer, Brown-Saltzman, Miers, & Squire, 2013). These obstacles may characterize a unit ethical climate that does not promote patient/family advocacy and nurse moral agency. Wolf et al. (2016) described the moral distress of ED nurses who are unable to meet their role obligations to provide safe and effective patient care in such environments.

The stress felt by Nancy in the presented ED case scenario is an example of this type of moral distress. Specific themes reflected in the case scenario and noted by Wolf and colleagues’ (2016) qualitative investigation relate to moral distress due to overemphasis on documentation, tasks, and metrics at the expense of patient care, as well as role conflicts resulting from hierarchical decision making. These same issues are reflected in a number of comments in Table 1 (e.g., overemphasis on documentation and measurement creating inefficiencies and a distraction to patient care).

Ethical Action
Nancy questions the physician’s decision to follow the sepsis quality metric and not write an order in the EHR for slow intravenous fluid administration. She verbally reports this information to the receiving ICU nurse and hopes “for the best outcome” for the patient. Could additional actions have been taken? Developing moral courage may assist in overcoming personal and institutional barriers to further nurse advocacy. Individuals with moral courage have developed skills of effective engagement and “willingness to speak out and do what is right in the face of forces that would lead a person to act in some other way” (Lachman, 2007, p. 131). Moral courage can also be “learned, practiced, and mentored” (Hawkins & Morse, 2014, p. 268). When moral courage and ethical action are thwarted by constraints outside the nurse’s control, moral distress can result.

Nurses experience moral distress, a concept first highlighted by Andrew Jameton in 1984, when they “know the right thing to do while being in a situation in which it is nearly impossible to do it.” (Jameton, 2017, p. 617). Jameton described three components that can apply