Legal issues concerning electronic health information: privacy, quality, and liability

Novel Generative Recurrent Neural Network Framework to Produce Accurate, Applicable, and Deidentified Synthetic Medical Data for Patients With Metastatic Cancer

PURPOSE

Sensitive patient data cannot be easily shared/analyzed, severely limiting the innovative progress of research, specifically for marginalized/under-represented populations. Existing methods of deidentification are subject to data breaches. The objective of this study was to develop a neural network capable of generating a synthetic version of data for patients with novel postoperative metastatic cancer.

METHODS

We analyzed a metastatic cancer patient cohort of 167,474 patients obtained from the National Surgical Quality Improvement Program. Twenty-seven clinical features were analyzed. We created a volume-matched synthetic cohort of 167,474 patients and a reduced-size synthetic cohort of 5,000 patients. The volume-matched and reduced-size synthetic cohorts were compared against the ground truth data to analyze differences in principal component distribution, underlying statistical properties/associations, intervariable correlations, and machine learning classifier performance when developed on the synthetic data.

RESULTS

Among 167,474 patients with metastatic cancer in the original data, 50,669 (30.3%) died within 30 days of their index surgery. Our model was able to accurately capture underlying statistical properties, principal components, and intervariable correlations within the ground truth data, yielding an accuracy of 93.2% with a loss of 0.21%, and develop synthetic data capable of training accurate machine learning classifiers. The reduced-size synthetic data accurately replicated all categorical variables and every continuous variable with statistically similar records (P > .05), with the sole exception of preoperative albumin (P < .05). The volume-matched synthetic data frame was able to accurately replicate all categorical variables (P > .05).

CONCLUSION

This described methodology can be applied to any structured medical data from any setting, significantly expedite scientific analysis/innovation, and be used to develop improved predictive classifiers with boosted tree-based algorithms, serving as the potential new gold standard of medical data sharing and data augmentation.

Research on Digital Technology Use in Cardiology: Bibliometric Analysis

Background

Digital technology uses in cardiology have become a popular research focus in recent years. However, there has been no published bibliometric report that analyzed the corresponding academic literature in order to derive key publishing trends and characteristics of this scientific area.

Objective

We used a bibliometric approach to identify and analyze the academic literature on digital technology uses in cardiology, and to unveil popular research topics, key authors, institutions, countries, and journals. We further captured the cardiovascular conditions and diagnostic tools most commonly investigated within this field.

Methods

The Web of Science electronic database was queried to identify relevant papers on digital technology uses in cardiology. Publication and citation data were acquired directly from the database. Complete bibliographic data were exported to VOSviewer, a dedicated bibliometric software package, and related to the semantic content of titles, abstracts, and keywords. A term map was constructed for findings visualization.

Results

The analysis was based on data from 12,529 papers. Of the top 5 most productive institutions, 4 were based in the United States. The United States was the most productive country (4224/12,529, 33.7%), followed by United Kingdom (1136/12,529, 9.1%), Germany (1067/12,529, 8.5%), China (682/12,529, 5.4%), and Italy (622/12,529, 5.0%). Cardiovascular diseases that had been frequently investigated included hypertension (152/12,529, 1.2%), atrial fibrillation (122/12,529, 1.0%), atherosclerosis (116/12,529, 0.9%), heart failure (106/12,529, 0.8%), and arterial stiffness (80/12,529, 0.6%). Recurring modalities were electrocardiography (170/12,529, 1.4%), angiography (127/12,529, 1.0%), echocardiography (127/12,529, 1.0%), digital subtraction angiography (111/12,529, 0.9%), and photoplethysmography (80/12,529, 0.6%). For a literature subset on smartphone apps and wearable devices, the Journal of Medical Internet Research (20/632, 3.2%) and other JMIR portfolio journals (51/632, 8.0%) were the major publishing venues.

Conclusions

Digital technology uses in cardiology target physicians, patients, and the general public. Their functions range from assisting diagnosis, recording cardiovascular parameters, and patient education, to teaching laypersons about cardiopulmonary resuscitation. This field already has had a great impact in health care, and we anticipate continued growth.

Women's experiences of safety apps for sexualized violence: a narrative scoping review

Background

Sexualized violence against women is a significant human rights problem worldwide. Safety apps have the capacity to provide women with resources to prevent or respond to experiences of sexualized violence.

Methods

The aim of the following study was to review the scope of the literature on women’s experiences of safety apps related to sexualized violence. The databases Embase, MEDLINE, PsycINFO, and Scopus were systematically searched, and seven studies were included in this review.

Results

Thematic analysis identified the following themes in the literature: (1) security; (2) accessibility; and (3) knowledge.

Conclusion

The gaps in the literature are identified and implications and recommendations for future research is discussed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12292-5.

Distributed learning from multiple EHR databases: Contextual embedding models for medical events

Electronic health record (EHR) data provide promising opportunities to explore personalized treatment regimes and to make clinical predictions. Compared with regular clinical data, EHR data are known for their irregularity and complexity. In addition, analyzing EHR data involves privacy issues and sharing such data is often infeasible among multiple research sites due to regulatory and other hurdles. A recently published work uses contextual embedding models and successfully builds one predictive model for more than seventy common diagnoses. Despite of the high predictive power, the model cannot be generalized to other institutions without sharing data. In this work, a novel method is proposed to learn from multiple databases and build predictive models based on Distributed Noise Contrastive Estimation (Distributed NCE). We use differential privacy to safeguard the intermediary information sharing. The numerical study with a real dataset demonstrates that the proposed method not only can build predictive models in a distributed manner with privacy protection, but also preserve model structure well and achieve comparable prediction accuracy. The proposed methods have been implemented as a stand-alone Python library and the implementation is available on Github (https://github.com/ziyili20/DistributedLearningPredictor) with installation instructions and use-cases.

The Importance of Relevance: Willingness to Share eHealth Data for Family Medicine Research

Objective: To determine the proportion of family medicine patients unwilling to allow their eHealth data to be used for research purposes, and evaluate how patient characteristics and the relevance of research impact that decision. Design: Cross-sectional questionnaire. Setting: Acute care respiratory clinic or an outpatient family medicine clinic in Montreal, Quebec. Participants: Four hundred seventy-four waiting room patients recruited via convenience sampling. Main Outcome Measures: A self-administered questionnaire collected data on age, gender, employment status, education, mother tongue and perceived health status. The main outcome of was self-reported relevance of three research scenarios and willingness or refusal to share their anonymized data. Responses were compared for family practice vs. specialty care patients. Results: The questionnaire was completed by 229 family medicine respondents and 245 outpatient respondents. Almost a quarter of all respondents felt the research was not relevant. Family medicine patients (15.7%) were unwilling to allow their data to be used for at least one scenario vs. 9.4% in the outpatient clinic. Lack of relevance (OR 11.55; 95% CI 5.12-26.09) and being in family practice (OR 2.13; 95% CI 1.06-4.27) increased the likelihood of refusal to share data for research. Conclusion: Family medicine patients were somewhat less willing to share eHealth data, but the overall refusal rate indicates a need to better engage patients in understanding the significance of full access to eHealth data for the purposes of research. Personal relevance of the research had a strong impact on the responses arguing for better efforts to make research more pertinent to patients.

Revisiting public health informatics: patient privacy concerns

Purpose

Expanding networks of data portals and repositories linked to electronic patient record systems, along with advances in information technology, have created both new opportunities in improving public health and new challenges in protecting patient privacy. The purpose of this paper is to review stakeholder perspectives and provide a framework for promoting implementation of current privacy protection improvement recommendations.

Design/methodology/approach

This paper summarizes a workshop session discussion stemming from the 2017 Information Technology and Communication in Health (ITCH) biennial international conference in Victoria, British Columbia, Canada. The perspectives within health service research, journalism, informatics and privacy protection were represented.

Findings

Problems underlying gaps in privacy protection in the USA and Canada, along with then-current changes recommended by public health leaders as well as Information and Privacy Commissioners, were identified in a session of the 2015 ITCH conference. During the 2017 conference, a workshop outlined the current situation, identifying ongoing challenges and a lack of significant progress. This paper summarizes that 2017 discussion identifying political climate as the major impediment to progress on this issue. It concludes with a framework to guide the path forward.

Originality/value

This paper provides an international perspective to problems, resources and solution pathways with links useful to readers in all countries.

The Norwegian National Summary Care Record: a qualitative analysis of doctors' use of and trust in shared patient information

BACKGROUND

This paper explores Norwegian doctors' use of and experiences with a national tool for sharing core patient health information. The summary care record (SCR; the Kjernejournal in Norwegian) is the first national system for sharing patient information among the various levels and institutions of health care throughout the country. The health authorities have invested heavily in the development, implementation and deployment of this tool, and as of 2017 all Norwegian citizens have a personalised SCR. However, as there remains limited knowledge about health professionals' use of, experiences with and opinions regarding this new tool, the purpose of this study was to explore doctors' direct SCR experiences.

METHODS

We conducted 25 in-depth interviews with 10 doctors from an emergency ward, 5 doctors from an emergency clinic and 10 doctors from 5 general practitioner offices. We then transcribed, thematically coded and analysed the interviews utilising a grounded theory approach.

RESULTS

The SCRs contain several features for providing core patient information that is particularly relevant in acute or emergency situations; nonetheless, we found that the doctors generally used only one of the tool's six functions, namely, the pharmaceutical summary. In addition, they primarily used this summary for a few subgroups of patients, including in the emergency ward for unconscious patients, for elderly patients with multiple prescriptions and for patients with substance abuse conditions. The primary difference of the pharmaceutical summary compared with the other functions of the tool is that patient information is automatically updated from a national pharmaceutical server, while other clinically relevant functions, like the critical information category, require manual updates by the health professionals themselves, thereby potentially causing variations in the accuracy, completeness and trustworthiness of the data.

CONCLUSION

Therefore, we can assume that the popularity of the pharmaceutical summary among doctors is based on their preference to place their trust in - and therefore more often utilise - automatically updated information. In addition, the doctors' lack of trust in manually updated information might have severe implications for the future success of the SCR and for similar digital tools for sharing patient information.

eRegistries: governance for electronic maternal and child health registries

BACKGROUND

The limited availability of maternal and child health data has limited progress in reducing mortality and morbidity among pregnant women and children. Global health agencies, leaders, and funders are prioritizing strategies that focus on acquiring high quality health data. Electronic maternal and child health registries (eRegistries) offer a systematic data collection and management approach that can serve as an entry point for preventive, curative and promotive health services. Due to the highly sensitive nature of reproductive health information, careful consideration must be accorded to privacy, access, and data security. In the third paper of the eRegistries Series, we report on the current landscape of ethical and legal governance for maternal and child health registries in developing countries.

METHODS

This research utilizes findings from two web-based surveys, completed in 2015 that targeted public health officials and health care providers in 76 countries with high global maternal and child mortality burden. A sample of 298 public health officials from 64 countries and 490 health care providers from 59 countries completed the online survey. Based on formative research in the development of the eRegistries Governance Guidance Toolkit, the surveys were designed to investigate topics related to maternal and child health registries including ethical and legal issues.

RESULTS

According to survey respondents, the prevailing legal landscape is characterized by inadequate data security safeguards and weak support for core privacy principles. Respondents from the majority of countries indicated that health information from medical records is typically protected by legislation although legislation dealing specifically or comprehensively with data privacy may not be in place. Health care provider trust in the privacy of health data at their own facilities is associated with the presence of security safeguards.

CONCLUSION

Addressing legal requirements and ensuring that privacy and data security of women's and children's health information is protected is an ethical responsibility that must not be ignored or postponed, particularly where the need is greatest. Not only are the potential harm and unintended consequences of inaction serious for individuals, but they could impact public trust in health registries leading to decreased participation and compromised data integrity.

Patient consent principles and guidelines for e-consent: a New Zealand perspective

E-consent systems are attracting considerable interest as healthcare providers increasingly apply information technology and management to plan and deliver high-quality and cost-effective healthcare. These systems can ensure that patients are informed about the consequences of clinical intervention or the use to which their personal health information is put, as well as able to log the conditions of consent and create an audit trail. This article considers the nature of patient consent and the control of information before outlining the characteristics, benefits and limitations of e-consent systems. It then surveys international developments in e-consent before describing a project to develop a framework for such consent in New Zealand. The results of this project offer recommendations for further development and implementation of the framework.

Closing the Gap: Supporting Patients' Transition to Self-Management after Hospitalization

Patients going home after a hospitalization face many challenges. This transition period exposes patients to unnecessary risks related to inadequate preparation prior to leaving the hospital, potentially leading to errors and patient harm. Although patients engaging in self-management have better health outcomes and increased self-efficacy, little is known about the processes in place to support and develop these skills for patients leaving the hospital. Through qualitative interviews and observations of 28 patients during and after their hospitalizations, we explore the challenges they face transitioning from hospital care to self-management. We identify three key elements in this process: knowledge, resources, and self-efficacy. We describe how both system and individual factors contribute to breakdowns leading to ineffective patient management. This work expands our understanding of the unique challenges faced by patients during this difficult transition and uncovers important design opportunities for supporting crucial yet unmet patient needs.

Ethical aspects in eHealth – design of a privacy-friendly system

Purpose

– The medical advances and historical fluctuations in the demographics are contributing to the rise of the average age. These changes are increasing the pressure to organize adequate care to a growing number of individuals. As a way to provide efficient and cost-effective care, eHealth systems are gaining importance. However, this trend is creating new ethical concerns. Major issues are privacy and patients’ control over their data. To deploy these systems on a large scale, they need to offer strict privacy protection. Even though many research proposals focus on eHealth systems and related ethical requirements, there is an evident lack of practical solutions for protecting users’ personal information. The purpose of this study is to explore the ethical considerations related to these systems and extract the privacy requirements. This paper also aims to put forth a system design which ensures appropriate privacy protection.

Design/methodology/approach

– This paper investigates the existing work in the area of eHealth systems and the related ethical considerations, which establish privacy as one of the main requirements. It lists the ethical requirements and data protection standards that a system needs to fulfil and uses them as a guideline for creating the proposed design.

Findings

– Even though privacy is considered to be a paramount aspect of the eHealth systems, the existing proposals do not tackle this issue from the outset of the design. Consequently, introducing privacy at the final stages of the system deployment imposes significant limitations and the provided data protection is not always to the standards expected by the users.

Originality/value

– This paper motivates the need for addressing ethical concerns in the eHealth domain with special focus on establishing strict privacy protection. It lists the privacy requirements and offers practical solutions for developing a privacy-friendly system and takes the approach of privacy-by-design. Additionally, the proposed design is evaluated against ethical principles as proposed in the existing literature. The aim is to show that technological advances can be used to improve quality and efficiency of care, while the usually raised concerns can be avoided.

Paperless anesthesia: uses and abuses of these data

Demonstrably accurate records facilitate clinical decision making, improve patient safety, provide better defense against frivolous lawsuits, and enable better medical policy decisions. Anesthesia Information Management Systems (AIMS) have the potential to improve on the accuracy and reliability of handwritten records. Interfaces with electronic recording systems within the hospital or wider community allow correlation of anesthesia relevant data with biochemistry laboratory results, billing sections, radiological units, pharmacy, earlier patient records, and other systems. Electronic storage of large and accurate datasets has lent itself to quality assurance, enhancement of patient safety, research, cost containment, scheduling, anesthesia training initiatives, and has even stimulated organizational change. The time for record making may be increased by AIMS, but in some cases has been reduced. The question of impact on vigilance is not entirely settled, but substantial negative effects seem to be unlikely. The usefulness of these large databases depends on the accuracy of data and they may be incorrect or incomplete. Consequent biases are threats to the validity of research results. Data mining of biomedical databases makes it easier for individuals with political, social, or economic agendas to generate misleading research findings for the purpose of manipulating public opinion and swaying policymakers. There remains a fear that accessibility of data may have undesirable regulatory or legal consequences. Increasing regulation of treatment options during the perioperative period through regulated policies could reduce autonomy for clinicians. These fears are as yet unsubstantiated.

Comparative effectiveness research and big data: balancing potential with legal and ethical considerations

Big data holds big potential for comparative effectiveness research. The ability to quickly synthesize and use vast amounts of health data to compare medical interventions across settings of care, patient populations, payers and time will greatly inform efforts to improve quality, reduce costs and deliver more patient-centered care. However, the use of big data raises significant legal and ethical issues that may present barriers or limitations to the full potential of big data. This paper addresses the scope of some of these legal and ethical issues and how they may be managed effectively to fully realize the potential of big data.

Big data and ambulatory care: breaking down legal barriers to support effective use

Big data is heralded as having the potential to revolutionize health care by making large amounts of data available to support care delivery, population health, and patient engagement. Critics argue that big data's transformative potential is inhibited by privacy requirements that restrict health information exchange. However, there are a variety of permissible activities involving use and disclosure of patient information that support care delivery and management. This article presents an overview of the legal framework governing health information, dispels misconceptions about privacy regulations, and highlights how ambulatory care providers in particular can maximize the utility of big data to improve care.

Semantic Normalization and Query Abstraction Based on SNOMED-CT and HL7: Supporting Multicentric Clinical Trials

Advances in the use of omic data and other biomarkers are increasing the number of variables in clinical research. Additional data have stratified the population of patients and require that current studies be performed among multiple institutions. Semantic interoperability and standardized data representation are a crucial task in the management of modern clinical trials. In the past few years, different efforts have focused on integrating biomedical information. Due to the complexity of this domain and the specific requirements of clinical research, the majority of data integration tasks are still performed manually. This paper presents a semantic normalization process and a query abstraction mechanism to facilitate data integration and retrieval. A process based on well-established standards from the biomedical domain and the latest semantic web technologies has been developed. Methods proposed in this paper have been tested within the EURECA EU research project, where clinical scenarios require the extraction of semantic knowledge from biomedical vocabularies. The aim of this paper is to provide a novel method to abstract from the data model and query syntax. The proposed approach has been compared with other initiatives in the field by storing the same dataset with each of those solutions. Results show an extended functionality and query capabilities at the cost of slightly worse performance in query execution. Implementations in real settings have shown that following this approach, usable interfaces can be developed to exploit clinical trial data outcomes.

A method to manage and share anti-retroviral (ARV) therapy information of human immunodeficiency virus (HIV) patients in Vietnam

Management of antiretroviral (ARV) drug and HIV patients data is an important component of Vietnam Administration of HIV/AIDS Control (VAAC) Department and hospitals/health care units when people often travel in other places of Vietnam; therefore, it would lead to a number of medical errors in treatment as well as patients do not adhere to ARV therapy. In this paper, we describe a system that manages and shares antiretroviral therapy information of 4438 HIV patients in three healthcare centers in Hanoi capital of Vietnam. The overall design considerations, architecture and the integration of centralized database and decentralized management for the system are also presented. The findings from this study can serve as a guide to consider in the implementation model of health care to manage and share information of patients not only in HIV infection, but also in the other chronic and non-communicable diseases.

Ethics and Privacy Considerations for Systems Biology Applications in Predictive and Personalized Medicine

Integrative analysis and modeling of the omics data using systems biology have led to growing interests in the development of predictive and personalized medicine. Personalized medicine enables future physicians to prescribe the right drug to the right patient at the right dosage, by helping them link each patient’s genotype to their specific disease conditions. This chapter shares technological, ethical, and social perspectives on emerging personalized medicine applications. First, it examines the history and research trends of pharmacogenomics, systems biology, and personalized medicine. Next, it presents bioethical concerns that arise from dealing with the increasing accumulation of biological samples in many biobanking projects today. Lastly, the chapter describes growing concerns over patient privacy when large amount of individuals’ genetic data and clinical data are managed electronically and accessible online.

Transforming Public Servants' Health Care Organization in Greece through the Implementation of an Electronic Referral Project

OBJECTIVE

The Greek Public Servants' Health Care Organization aiming to organize, monitor, and enhance the health care services provided to 1,500,000 public servants decided to respond to the national alert of the economic crisis through the reduction of costs caused by diagnostic tests (€300,000,000 claims for 2008), to improve working conditions of contracted physicians and laboratories, and to enhance services provided to insured members. In September 2010, the Greek Public Servants' Health Care Organization initiated a pilot project that electronically records the prescription process of the diagnostic tests, which is Web-based, is open source, and was provided for free to the contracted physicians and diagnostic centers.

METHODS

In this article, we present some interesting findings resulting from the implementation of the pilot electronic referral project by examining a 9-month period.

RESULTS

Fifty-eight percent of the physicians had the necessary equipment for the operation of the system, more than 3600 physicians used it, 17,495 public servants had been served through the system, and 178,456 paraclinical examinations had been prescribed with a cost of €1,394,980. In addition, the analysis revealed that the implementation of an electronic referral system could provide significant benefits, such as a faster referral process, valid and coherent information, minimization of the risk of misinterpreting the electronic referral due to illegibility of handwriting, and improvement in quality of services.

CONCLUSIONS

The Greek electronic referral system was one of the first attempts toward creating the basis of a society of transparency and cost control. The lessons learnt from this article should not be ignored in the process of redesigning and improving the electronic referral system for Greece.

Ethics in medical research: General principles with special reference to psychiatry research

Ethics is an understanding of the nature of conflicts arising from moral imperatives and how best we may deal with them. Ethics in medical research deals with the conflicts of interest across various levels. Guidelines have been proposed for standardized ethical practice throughout the globe. The four fundamental principles of ethics which are being underscored are autonomy, non-maleficence, beneficence, and justice. Some special ethical issues have particular relevance to psychiatric research arising primarily from the specific vulnerabilities of those with mental illness and the risks posed by some research methodologies. Accordingly, sensitivity is required in the design of psychiatric research. It is suggested that though the value of published guidelines and the help that may be available from research ethics committees is quite great, the primary responsibility for maintaining high standards of practice in research rests with research workers themselves.

Obtaining providers' 'buy-in' and establishing effective means of information exchange will be critical to HITECH's success

In enacting the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act, Congress set ambitious goals for the nation to integrate information technology into health care delivery. The provisions called for the electronic exchange of health information and the adoption and meaningful use of health information technology in health care practices and hospitals. We examined the marketplace and regulatory forces that influence HITECH's success and identify outstanding challenges, some beyond the provisions' control. To reach HITECH's goals, providers and patients must be persuaded of the value of health information exchange and support its implementation. Privacy concerns and remaining technical challenges must also be overcome. Achieving HITECH's goals will require well-aligned incentives, both visionary and practical pursuit of exchange infrastructure, and realistic assumptions about how quickly such wholesale change can be accomplished. The use of metrics to show adoption proceeding at a reasonable pace, increased flow of data across parties, and evidence that care is improving, at least in areas with robust systems, will be essential to persuade stakeholders that the initiative is progressing well and warrants continued investment.

Telemedicine: licensing and other legal issues

The growth of information technology and telecommunications has created promising opportunities for better, faster, more accessible, barrier-free health care; telemedicine (TM). The feasibility of many TM projects depends on resolving legal issues. Mastering technical issues or providing training remain important benchmarks for implementation of TM, but legal issues constrain progress. This article identifies the key legal issues, maps current legislation, and offers a forecast of necessary steps to expedite the dissemination of TM.

Physician privacy concerns when disclosing patient data for public health purposes during a pandemic influenza outbreak

Background

Privacy concerns by providers have been a barrier to disclosing patient information for public health purposes. This is the case even for mandated notifiable disease reporting. In the context of a pandemic it has been argued that the public good should supersede an individual's right to privacy. The precise nature of these provider privacy concerns, and whether they are diluted in the context of a pandemic are not known. Our objective was to understand the privacy barriers which could potentially influence family physicians' reporting of patient-level surveillance data to public health agencies during the Fall 2009 pandemic H1N1 influenza outbreak.

Methods

Thirty seven family doctors participated in a series of five focus groups between October 29-31 2009. They also completed a survey about the data they were willing to disclose to public health units. Descriptive statistics were used to summarize the amount of patient detail the participants were willing to disclose, factors that would facilitate data disclosure, and the consensus on those factors. The analysis of the qualitative data was based on grounded theory.

Results

The family doctors were reluctant to disclose patient data to public health units. This was due to concerns about the extent to which public health agencies are dependable to protect health information (trusting beliefs), and the possibility of loss due to disclosing health information (risk beliefs). We identified six specific actions that public health units can take which would affect these beliefs, and potentially increase the willingness to disclose patient information for public health purposes.

Conclusions

The uncertainty surrounding a pandemic of a new strain of influenza has not changed the privacy concerns of physicians about disclosing patient data. It is important to address these concerns to ensure reliable reporting during future outbreaks.

A secure protocol for protecting the identity of providers when disclosing data for disease surveillance

BACKGROUND

Providers have been reluctant to disclose patient data for public-health purposes. Even if patient privacy is ensured, the desire to protect provider confidentiality has been an important driver of this reluctance.

METHODS

Six requirements for a surveillance protocol were defined that satisfy the confidentiality needs of providers and ensure utility to public health. The authors developed a secure multi-party computation protocol using the Paillier cryptosystem to allow the disclosure of stratified case counts and denominators to meet these requirements. The authors evaluated the protocol in a simulated environment on its computation performance and ability to detect disease outbreak clusters.

RESULTS

Theoretical and empirical assessments demonstrate that all requirements are met by the protocol. A system implementing the protocol scales linearly in terms of computation time as the number of providers is increased. The absolute time to perform the computations was 12.5 s for data from 3000 practices. This is acceptable performance, given that the reporting would normally be done at 24 h intervals. The accuracy of detection disease outbreak cluster was unchanged compared with a non-secure distributed surveillance protocol, with an F-score higher than 0.92 for outbreaks involving 500 or more cases.

CONCLUSION

The protocol and associated software provide a practical method for providers to disclose patient data for sentinel, syndromic or other indicator-based surveillance while protecting patient privacy and the identity of individual providers.

Parental perceptions toward digital imaging and telemedicine for retinopathy of prematurity management

BACKGROUND

Telemedicine is an emerging technology with potential to improve care for retinopathy of prematurity (ROP). This study evaluates parental perceptions about digital imaging and telemedicine for ROP care.

METHODS

During a 1-year period, one parent of each infant who underwent wide-field retinal imaging for ROP was given a questionnaire designed to evaluate parental perceptions using a 5-point Likert-type scale. Five items assessed perceptions toward digital retinal imaging, and ten items assessed attitudes toward telemedicine. Construct validity of the questionnaire was examined using factor analysis. Responses were summarized using descriptive and correlational statistics.

RESULTS

Forty-two parents participated. Factor analysis extracted two factors explaining 79% of the total variance in digital retinal imaging items (Cronbach's alpha = 0.843), and three factors explaining 63% of the total variance in telemedicine items (Cronbach's alpha = 0.631). Among digital imaging items, the highest mean (+/-SD) score was for "digital pictures of my child's retinopathy should be included in the permanent medical record" (4.4 +/- 0.6), and the lowest was for "digital cameras and computers are reliable" (3.8 +/- 0.8). Among telemedicine items, the highest mean (+/-SD) score was for "technology will improve the quality of medical care for my child" (4.3 +/- 0.6), and the lowest was for "technology will make it harder for a patient and doctor to establish a good relationship" (2.6 +/- 1.1).

CONCLUSIONS

Parents reported positive perceptions about telemedical ROP diagnosis, but expressed some preference for face-to-face care. Telemedicine has potential to alter the nature of the patient-physician relationship.

A web-based remote radiation treatment planning system using the remote desktop function of a computer operating system: a preliminary report

We developed a web-based, remote radiation treatment planning system which allowed staff at an affiliated hospital to obtain support from a fully staffed central institution. Network security was based on a firewall and a virtual private network (VPN). Client computers were installed at a cancer centre, at a university hospital and at a staff home. We remotely operated the treatment planning computer using the Remote Desktop function built in to the Windows operating system. Except for the initial setup of the VPN router, no special knowledge was needed to operate the remote radiation treatment planning system. There was a time lag that seemed to depend on the volume of data traffic on the Internet, but it did not affect smooth operation. The initial cost and running cost of the system were reasonable.

Relationship between discharge practices and intensive care unit in-hospital mortality performance: evidence of a discharge bias

CONTEXT

Current intensive care unit performance measures include in-hospital mortality after intensive care unit admission. This measure does not account for deaths occurring after transfer to another hospital or soon after discharge and therefore, may be biased.

OBJECTIVE

Determine how transfer rates to other acute care hospitals and early post-discharge mortality rates impact hospital performance assessments using an in-hospital mortality model.

DESIGN, SETTING, AND PARTICIPANTS

Data were retrospectively collected on 10,502 eligible intensive care unit patients across 35 California hospitals between 2001 and 2004.

MEASURES

We calculated the rates of acute care hospital transfers and early post-discharge mortality (30-day overall mortality-30-day in-hospital mortality) for each hospital. We assessed hospital performance with standardized mortality ratios (SMRs) using the Mortality Probability Model III. Using regression models, we explored the relationship between in-hospital SMRs and the rates of hospital transfers or early post-discharge mortality. We explored the same relationship using a 30-day SMR.

RESULTS

In multivariable models, for each 1% increase in patients transferred to another acute care hospital, there was an in-hospital SMR reduction of -0.021 (-0.040-0.001). Additionally, a 1% increase in early post-discharge mortality was associated with an in-hospital SMR reduction of -0.049 (-0.142-0.045). Assessing hospital performance based upon 30-day mortality end point resulted in SMRs closer to 1.0 for hospitals at high and low ends of in-hospital mortality performance.

CONCLUSIONS

Variations in transfer rates and potentially discharge timing appear to bias in-hospital SMR calculations. A 30-day mortality model is a potential alternative that may limit this bias.

Where's the revolution? Digital technology and health care in the internet age

Despite the growing use of online resources, it is unclear how many Americans are using the World Wide Web for different health-related purposes and whether factors promoting use of the Internet in health care correspond with those affecting more traditional in-person and telemedicine encounters. This research uses a national public opinion survey to examine the degree to which health care consumers communicate through conventional, face-to-face consultation, telemedicine, or digital technology, and the relationship between these means of communication and respondent characteristics. Results indicate that few people are using digital technology to get information, communicate with health personnel, or make online medical purchases. Furthermore, less well educated, lower-income individuals living in rural areas tend to use the health care Internet less than others. Several policy measures need to be undertaken in order to accelerate the appropriate use of digital technology by health care consumers of all kinds. These include improving education and technological literacy and providing access to low-cost digital technology. Without a consumer complement to prevailing efforts to spur health information technology development and implementation on the part of providers, the promise of the digital revolution will continue to be limited to certain better-connected segments of the population.

Using technology to expedite screening and intervention for domestic abuse and neglect

OBJECTIVE

In response to escalation of community violence, the U.S. Department of Commerce funded Home Health VNA (HHVNA), serving the Merrimack River valley communities in Massachusetts and New Hampshire, for a project demonstrating innovative use of technology in screening for abuse and neglect.

DESIGN

All health care providers in the HHVNA were trained in screening through tools loaded on their personal digital assistants.

SAMPLE

The sample was comprised of patients served by HHVNA during the study period.

INTERVENTION

When a patient screened positive, the health care provider mobilized resources, including social workers, the office of elder services, or the local department of social services office for same-day follow-up.

OUTCOMES

Screening for abuse and neglect was mainstreamed into routine care. Health care providers noted significant reduction in redundant domestic abuse data collection. The close communication networks created enabled health care providers to mobilize resources, initiating same-day in-depth social work assessment and referrals to appropriate community agencies. Health care providers now transmit selected encrypted health information and mandated reports to official agencies.

CONCLUSIONS

Wedding technology with health care professionals' skills and knowledge can move prevention of and early intervention for domestic abuse and neglect to a new level of efficacy.

Considering something 'ELSE': ethical, legal and socio-economic factors in medical imaging and medical informatics

The focus on the use of existing and new technologies to facilitate advances in medical imaging and medical informatics (MIMI) is often directed to the technical capabilities and possibilities that these technologies bring. The technologies, though, in acting as a mediating agent alter the dynamics and context of information delivery in subtle ways. While these changes bring benefits in more efficient information transfer and offer the potential of better healthcare, they also disrupt traditional processes and practices which have been formulated for a different setting. The governance processes that underpin core ethical principles, such as patient confidentiality and informed consent, may no longer be appropriate in a new technological context. Therefore, in addition to discussing new methodologies, techniques and applications, there is need for a discussion of ethical, legal and socio-economic (ELSE) issues surrounding the use and application of technologies in MIMI. Consideration of these issues is especially important for the area of medical informatics which after all exists to support patients, healthcare practitioners and inform science. This paper brings to light some important ethical, legal and socio-economic issues related to MIMI with the aim of furthering an interdisciplinary approach to the increasing use of Information and Communication Technologies (ICT) in healthcare.

Ethics in public health research: privacy and public health at risk: public health confidentiality in the digital age

Public health agencies increasingly use electronic means to acquire, use, maintain, and store personal health information. Electronic data formats can improve performance of core public health functions, but potentially threaten privacy because they can be easily duplicated and transmitted to unauthorized people. Although such security breaches do occur, electronic data can be better secured than paper records, because authentication, authorization, auditing, and accountability can be facilitated. Public health professionals should collaborate with law and information technology colleagues to assess possible threats, implement updated policies, train staff, and develop preventive engineering measures to protect information. Tightened physical and electronic controls can prevent misuse of data, minimize the risk of security breaches, and help maintain the reputation and integrity of public health agencies.

Bioterrorism surveillance and privacy: intersection of HIPAA, the Common Rule, and public health law

The threat of bioterrorism in the wake of the September 11, 2001, terrorist attacks cannot be ignored. Syndromic surveillance, the practice of electronically monitoring and reporting real-time medical data to proactively identify unusual disease patterns, highlights the conflict between safeguarding public health while protecting individual privacy. Both the Health Insurance Portability and Accountability Act and the Common Rule (which promulgates protections for individuals in federally sponsored medical research programs) safeguard individuals. Public health law protects the entire populace; uneven state-level implementation lacks adequate privacy protections. We propose 3 models for a nationwide bioterrorism surveillance review process: a nationally coordinated systems approach to using protected health information, creating public health information privacy boards, expanding institutional review boards, or some combination of these.

Promoting regular mammography screening I. A systematic assessment of validity in a randomized trial

BACKGROUND

Most health promotion trials in cancer screening offer limited evidence of external validity. We assessed internal and external validity in a nationwide, population-based trial of an intervention to promote regular mammography screening.

METHODS

Beginning in September 2000, study candidates age 52 years and older (n = 23,000) were randomly selected from the National Registry of Women Veterans and sent an eligibility survey. Consistent with intention-to-treat principles for effectiveness trials, we randomly assigned eligible respondents and nonrespondents to one of five groups. We mailed baseline surveys to groups 1-3 followed by intervention materials of varying personalization to groups 1 and 2. We delayed mailing baseline surveys to two additional control groups to coincide with the mailing of postintervention follow-up surveys to groups 1-3 at year 1 (group 4) and year 2 (group 5). Mammography rates were determined from self-report and Veterans Health Administration records. To assess internal validity, we compared groups on participation and factors associated with mammography screening at each stage. To assess external validity, we compared groups 3, 4, and 5 on mammography rates at the most recent follow-up to detect any cueing effects of prior surveys and at the respective baselines to uncover any secular trends. We also compared nonparticipants with participants on factors associated with mammography screening at the trial's end.

RESULTS

We established study eligibility for 21,340 (92.8%) of the study candidates. Groups 1-3 were similar throughout the trial in participation and correlates of mammography screening. No statistically significant survey cueing effects or differences between nonparticipants and participants across groups were observed. Mammography screening rates over the 30 months preceding the respective baselines were lower in group 5 (82.3% by self-report) than in groups 1-4 (85.1%, P = .024, group 5 vs groups 1-4 combined), suggesting a decline over time similar to that reported for US women in general.

CONCLUSION

This systematic assessment provides evidence of the trial's internal and external validity and illustrates an approach to evaluating validity that is readily adaptable to future trials of behavioral interventions.

An evaluation of personal health information remnants in second-hand personal computer disk drives

Background

The public is concerned about the privacy of their health information, especially as more of it is collected, stored, and exchanged electronically. But we do not know the extent of leakage of personal health information (PHI) from data custodians. One form of data leakage is through computer equipment that is sold, donated, lost, or stolen from health care facilities or individuals who work at these facilities. Previous studies have shown that it is possible to get sensitive personal information (PI) from second-hand disk drives. However, there have been no studies investigating the leakage of PHI in this way.

Objectives

The aim of the study was to determine the extent to which PHI can be obtained from second-hand computer disk drives.

Methods

A list of Canadian vendors selling second-hand computer equipment was constructed, and we systematically went through the shuffled list and attempted to purchase used disk drives from the vendors. Sixty functional disk drives were purchased and analyzed for data remnants containing PHI using computer forensic tools.

Results

It was possible to recover PI from 65% (95% CI: 52%-76%) of the drives. In total, 10% (95% CI: 5%-20%) had PHI on people other than the owner(s) of the drive, and 8% (95% CI: 7%-24%) had PHI on the owner(s) of the drive. Some of the PHI included very sensitive mental health information on a large number of people.

Conclusions

There is a strong need for health care data custodians to either encrypt all computers that can hold PHI on their clients or patients, including those used by employees and subcontractors in their homes, or to ensure that their computers are destroyed rather than finding a second life in the used computer market.

Linking laboratory and medication data: new opportunities for pharmacoepidemiological research

Transfer of automated laboratory data collected during routine clinical care from the laboratory information system into a database format that enables linkage to other administrative (e.g., patient characteristics) or clinical (e.g., medication, diagnoses, procedures) data provides a valuable tool for clinical epidemiological research. It allows the investigation of biochemical characteristics of diseases, therapeutic effects and diagnostic and/or prognostic markers for disease with easy access and at relatively low cost. To this end, the Utrecht Patient Oriented Database (UPOD), an infrastructure of relational databases comprising data on patient characteristics, laboratory test results, medication orders, hospital discharge diagnoses and medical procedures for all patients treated at the University Medical Centre Utrecht since January 2004, was established. Current research within UPOD is focused on the innovative linkage of laboratory and medication data, which, for example, makes it possible to assess the quality of pharmacotherapy in clinical practice, to investigate interference between laboratory tests and drugs, to study the risk of adverse drug reactions, and to develop diagnostic and prognostic markers or algorithms for adverse drug reactions. Although recently established, we believe that UPOD broadens the opportunities for clinical pharmacoepidemiological research and can contribute to patient care from a laboratory perspective.