Legal and ethical issues of E-health 1

Healthcare through Internet: How ethical and legal is it?

Dr. Mohammad Ashrafzadeh, DHA

 Legal and ethical issues of E-health 2

INTRODUCTION

Healthcare technology and use of computer based programs have been going

through massive changes. E-health is a new paradigm that is the direct cause of advances in

network technologies, telecommunication and information systems.

Tan (n.d.) asserted that “…new experience and knowledge that crosses traditional

disciplinary boundaries, particularly cross-disciplinary and multidisciplinary research in the

fields of information technology and health care, along with emerging knowledge to

promote evidence-based medicine, e-medicine, and remote e-health services, are causing

not just episodic but systemic transformation of traditional health care systems and

environments” (p. 4). In order to transform the business of healthcare, use of electronic

commerce (e-commerce) and electronic business (e-business) concepts initiated efforts to

use the availability of low cost and high speed Internet related or wireless technology.

Discussion

The advent of tele-health has led to the provision of e-health. E-health, simply put,

symbolizes the electrification of all aspects of healthcare. ValiCert’s report (2001) indicated

that the META Group Trend teleconference in 1Q2000 titled "A Practical Introduction to E-

Health" presented their categorization of e-Health as the 5 Cs: Care, Content, Commerce,

Connectivity, and Computer Applications.

Healthcare systems and organizations are developing and installing major Internet

based applications in several areas including enrollment, human resources, claim

processing, and eligibility. As it is common knowledge the healthcare industry in the

United States produces more paperwork than any other industries. ValiCert (2001) reported

that according to the Health Care Financing Administration (HCFA), U.S. healthcare
 Legal and ethical issues of E-health 3

expenditures totaled $1.15 trillion in 1998. On the whole, healthcare expenditure continues

to increase due to several factors including the aging population, price of medicine and

healthcare technology, bigger investment in information technology, and advanced medical

knowledge. ValiCert’ report continued to indicate that the nation's total health bill in 2004

was $1.87 trillion, or 16% of the gross domestic product (GDP). In 1980, the health care

cost was just 9% of GDP and by 2008 analysts estimate the spending number to reach

$2.16 trillion (NPR, 2006). According to the ValiCert’s report for every dollar spent on

healthcare, it is estimated that 20 to 25 cents is spent o administrative overhead. This

estimation of administrative overhead translated to a “whopping $250 billion spent in 1998

on paperwork, unnecessary or duplicative tasks and improper billing” (p. 3).

This situation also exists in mental health care. In order to eliminate the duplicative

tasks and inappropriate billing, psychotherapists tend to use a promising portal, the

Internet. However, the delivery of services in behavioral e-health is still at the stage of

infancy. Maheu (2001) indicated that guidance for structuring the interactions with patients

in behavioral healthcare can be found in the conventional telehealth research literature,

where it has been discussed that uploading the traditions and requirements of expert

practice is possible while using telecommunication technology.

Maheu (2001) citing Reed, McLaughlin, and Milholland, (2000) asserted that

telecommunication technologies have the tendency for development into profitable but not

necessarily better or more effective health care system when they are driven by commercial

rather than practitioner’s interests. More specifically, as several behavioral e-health web

sites offer information and community support, some have indiscriminately offer direct
 Legal and ethical issues of E-health 4

professional care to consumer without a rigor research to establish safety and efficacy or

efficiency in services delivered.

One of the main concerns of American consumers in the healthcare industry is

confidentiality of security of their healthcare issues. With an increasing number of

healthcare organizations conducting business via electronic transactions, the public has

grown concerned about confidentiality of their personal healthcare information (Valicert,

2001). Hacking and identity theft has become the concern of the day and public continues

demanding a solution by the government. This issue had become very urgent and needed to

be addressed immediately. Congress focused on some of these issues in a section of Health

Insurance Portability and Accountability Act (HIPAA) entitled Administrative

Simplification, which was the topic of the day and under spot light in 2000 and 2001.

Valicert (2001) asserted that “This section of HIPAA mandates the use of a series of

electronic claims processing standards. HIPAA administrative simplification regulations

include: patient and provider identifiers, and code sets.” The Department of Health and

Human (2003) issued a fact sheet whereupon asserted that HIPPA Administrative

Simplification rules include:

1. Electronic health care transaction and code sets

2. Health information privacy (final rule issued);

3. Unique identifier for employers (final rule issued);

4. Security requirements (final rule issued);

5. Unique identifier for providers

6. Unique identifier for health plans

7. Enforcement procedures
 Legal and ethical issues of E-health 5

However, Valicert (2001) pointed out that congress recognized that the

standardization of information formats and greater use of electronic technology present

additional privacy and security risk. In summary, HIPAA focus areas may be listed as

follows:

1. Transaction Standards, Code Set Definitions, and Unique Identifiers

2. Data Security

3. Information Privacy

4. Auditing and Monitoring

HIPAA rules were established to provide ethical and legal provision of e-health. To

that end accreditation bodies such as Joint Commission on Accreditation of Healthcare

Organizations (JCAHO), and Commission on Accreditation of Rehabilitation Facilities

(CARF) and other accreditation groups developed their own set of standard for healthcare

organizations. Utilization Review Accreditation Commission (URAC) (2005), a healthcare

accrediting association, reported that Health Internet Ethics or hi-ethics indicates 14

principles for health web sites, demonstrating a commitment to ensure that “consumers can

realize the full benefits of the Internet to improve their health and that of their families.”

These principles are:

1. Privacy policies

2. Enhanced privacy protection for health related personal information

3. Safeguarding consumer privacy in relationships with third parties

4. Disclosure of ownership and financial sponsorship

5. Identifying advertising and health information content sponsored by third parties

6. Promotional offers, rebates, and free items or services

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7. Quality of health information content

8. Authorship and accountability

9. Disclosure of source and validation for self-assessment tools

10. Professionalism in the online environment

11. Qualifications of those responsible for health care services delivered via the web

site

12. Transparency of interactions, candor and trustworthiness

13. Disclosure of limitations of the site as a source of health care services

14. Mechanism for consumer feedback concerning the web site

Before providing mental healthcare services through technology, the service

providers must gain and document training for the use of specific technologies to provide

psychotherapy. As a word of caution to the practitioners, they must take care that

technology that is being used in the provision of mental care is supported by sound

empirical evidence of its efficacy. Several facets of working with technology require the

service provider to be aware of hidden factors that may positively or negatively influence

communication with the patients. These factors can be technical proficiency and legal

training.

Technical proficiency could include e-mail, which is dependent upon participants'

writing skills and can lead to a greater number of misinterpretations. Maheu (2001) pointed

out that chat rooms have not been researched adequately regarding their influence on the

communication of people with social or emotional difficulties. Initial assumption rotates

around their potential for eliciting incomplete or impulsive thoughts, due to the time

pressure created by the delay in sending and receiving messages. Videoconferencing can be
 Legal and ethical issues of E-health 7

disturbing and distracting drawing attention to factors in the peripheral movement, such as

tapping, rocking, or scratching one’s face or hair. Another factor that may be of concern in

video-conferencing is the presence of the video camera, which may place the person in an

awkward position if the person is camera shy. Reliability of therapeutic contact is also

crucial when establishing rapport and delivering services face-to-face. Internet services are

still not completely reliable, especially if the person uses dial-up services rather than high-

speed services. In these situations and given the particular patient and condition, it could

confusing and harmful to a patient to lose Internet contact with the therapist. Backup plans

and procedures and other informed consents issues must be discussed thoroughly before

treatment.

Legal training is another important aspect of e-health. Maheu (2001) indicated that

healthcare professionals are caught in a bind of having access to several technologies for

practice, but not having legal protections for themselves or their patients. Legal and

legislative bodies are in process of establishing and instituting laws in this area and there

are number of new regulations and laws that are still unknown or new to the legal as well

as healthcare communities.

Conclusion

Considering the above issues, State of Pennsylvania has started a substantial change

toward provision of quality in mental health access and treatment through Internet. As part

of this massive undertaking, the State’s Department of Public Welfare (DPW) has

established different access points. Home and Community Services Information System

(HCSIS) is an information system that serves DPW program offices that support all Home
 Legal and ethical issues of E-health 8

and Community Based Services (HCBS) waivers and programs. In addition, the department

offers a new state of the art database for claim processing through Internet.

Another step to this end is the use of PROMISe database. PROMISe is the name of

a new claims processing and management information system for the Pennsylvania

Department of Public Welfare. PROMISe is the acronym for Provider Reimbursement and

Operations Management Information System in electronic format. PROMISe is online, real

time, HIPAA ready, and initiated as of March of 2004. PROMISe incorporates claims

processing and activities for the Department of Public Welfare programs:

• Office of Medical Assistance Programs (OMAP)

• Offices of Mental Health and Substance Abuse

• Office of Mental Retardation

• Office of Social Programs

• Departments of Aging, Health and Education

As in the state of Pennsylvania, HIPAA rules and policies have initiated a revolution

in the use of technology in the healthcare system across the country. Both in national and

state levels considerable changes and upgrades were initiated due to the advent of HIPAA.

Since implementation of HIPAA rules, States’ Departments of Health and Human services

as well as the healthcare organizations have undertaken upgrades of their systems

mainframes in order to meet the privacy act and provide ethical services for the population.

References
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Department of Health and Human Services, (2003). The fact sheet. Retrieved July 10, 2006

from http://www.hhs.gov/news/press/2002pres/hipaa.html

Maheu, M. (2001). Exposing the risk, yet moving forward: A behavioral E-health model.

Retrieved July 11, 2006 from http://jcmc.indiana.edu/vol6/issue4/maheu.html

NPR News. (2006). Generic drugs ease U.S. health care bill. Retrieved July 10, 2006 from

http://www.npr.org/templates/story/story.php?storyId=5146544

Tan, J. (n.d.) The next health care frontier. E-healthcare information system, 4-5. Retrieved

July 8, 2006 from

http://media.wiley.com/product_data/excerpt/85/07879661/0787966185.pdf

ValiCert. (2001). Insurance claim processing in e-health era: Leveraging the internet to

securely conduct business processes. 3-4. Retrieved July 10, 2006 from

http://www.healthleadersmedia.com/pdf/white_papers/wp_valicert_1201.pdf

URAC, (2005). URAC health web site accreditation tames Internet’s wild, wild west.

Retrieved July 11, 2006 from

http://www.healthleadersmedia.com/pdf/white_papers/wp_URAC_022205.pdf