Tools to foster responsibility in digital solutions that operate with or without artificial intelligence: A scoping review for health and innovation policymakers

BACKGROUND

Digital health solutions that operate with or without artificial intelligence (D/AI) raise several responsibility challenges. Though many frameworks and tools have been developed, determining what principles should be translated into practice remains under debate. This scoping review aims to provide policymakers with a rigorous body of knowledge by asking: 1) what kinds of practice-oriented tools are available?; 2) on what principles do they predominantly rely?; and 3) what are their limitations?

METHODS

We searched six academic and three grey literature databases for practice-oriented tools, defined as frameworks and/or sets of principles with clear operational explanations, published in English or French from 2015 to 2021. Characteristics of the tools were qualitatively coded and variations across the dataset identified through descriptive statistics and a network analysis.

FINDINGS

A total of 56 tools met our inclusion criteria: 19 health-specific tools (33.9%) and 37 generic tools (66.1%). They adopt a normative (57.1%), reflective (35.7%), operational (3.6%), or mixed approach (3.6%) to guide developers (14.3%), managers (16.1%), end users (10.7%), policymakers (5.4%) or multiple groups (53.6%). The frequency of 40 principles varies greatly across tools (from 0% for 'environmental sustainability' to 83.8% for 'transparency'). While 50% or more of the generic tools promote up to 19 principles, 50% or more of the health-specific tools promote 10 principles, and 50% or more of all tools disregard 21 principles. In contrast to the scattered network of principles proposed by academia, the business sector emphasizes closely connected principles. Few tools rely on a formal methodology (17.9%).

CONCLUSION

Despite a lack of consensus, there is a solid knowledge-basis for policymakers to anchor their role in such a dynamic field. Because several tools lack rigour and ignore key social, economic, and environmental issues, an integrated and methodologically sound approach to responsibility in D/AI solutions is warranted.

When robots care: Public deliberations on how technology and humans may support independent living for older adults

While assistive robots receive growing attention as a potential solution to support older adults to live independently, several scholars question the underlying social, ethical and health policy assumptions. One perplexing issue is determining whether assistive robots should be introduced to supplement caregivers or substitute them. Current state of knowledge indicates that users and caregivers consider that robots should not aim to replace humans, but could perform certain tasks. This begs the question of the nature and scope of the tasks that can be delegated to robots and of those that should remain under human responsibility. Considering that such tasks entail a range of actions that affect the meaning of caregiving and care receiving, this article offers sociological insights into the ways in which members of the public reason around assistive actions, be they performed by humans, machines or both. Drawing on a prospective public deliberation study that took place in Quebec (Canada) in 2014 with participants (n = 63) of different age groups, our findings clarify how they envisage what robots can and cannot do to assist older people, and when and why delegating certain tasks to robots becomes problematic. A better understanding of where the publics draw a limit in the substitution of humans by robots refocuses policymakers' attention on what good care entails in modern healthcare systems.

Teleconsultation: Rejected and Emerging Uses

Objective: The aim of this paper is to analyse telemedicine as a new means to improve health care accessibility.

Method: A case study design was used to understand how medical specialists perceived, made sense of, and appropriated a teleconsultation system.

Results and Conclusions: The technology was used neither in the manner nor to the extent anticipated by its designers. A fundamental modification to the traditional medical consultation process has emerged. Unable to be used as a substitute to the traditional medical consultation process, the teleconsultation system imposes a greater burden on the shoulders of participating physicians who, after a few trials, returned to their traditional mode of practice.

Assessment of a multimedia-based prospective method to support public deliberations on health technology design: participant survey findings and qualitative insights

Background

Using a combination of videos and online short stories, we conducted four face-to-face deliberative workshops in Montreal (Quebec, Canada) with members of the public who later joined additional participants in an online forum to discuss the social and ethical implications of prospective technologies. This paper presents the participants’ appraisal of our intervention and provides novel qualitative insights into the use of videos and online tools in public deliberations.

Methods

We applied a mixed-method study design. A self-administered survey contained open- and close-ended items using a 5-level Likert-like scale. Absolute frequencies and proportions for the close-ended items were compiled. Qualitative data included field notes, the transcripts of the workshops and the participants’ contributions to the online forum. The qualitative data were used to flesh out the survey data describing the participants’ appraisal of: 1) the multimedia components of our intervention; 2) its deliberative face-to-face and online processes; and 3) its perceived effects.

Results

Thirty-eight participants contributed to the workshops and 57 to the online forum. A total of 46 participants filled-in the survey, for a response rate of 73 % (46/63). The videos helped 96 % of the participants to understand the fictional technologies and the online scenarios helped 98 % to reflect about the issues raised. Up to 81 % considered the arguments of the other participants to be well thought-out. Nearly all participants felt comfortable sharing their ideas in both the face-to-face (89 %) and online environments (93 %), but 88 % preferred the face-to-face workshop. As a result of the intervention, 85 % reflected more about the pros and cons of technology and 94 % learned more about the way technologies may transform society.

Conclusions

This study confirms the methodological feasibility of a deliberative intervention whose originality lies in its use of videos and online scenarios. To increase deliberative depth and foster a strong engagement by all participants, face-to-face and online components need to be well integrated. Our findings suggest that online tools should be designed by considering, one the one hand, the participants’ self-perceived ability to share written comments and, on the other hand, the ease with which other participants can respond to such contributions.

How does venture capital operate in medical innovation?

While health policy scholars wish to encourage the creation of technologies that bring more value to healthcare, they may not fully understand the mandate of venture capitalists and how they operate. This paper aims to clarify how venture capital operates and to illustrate its influence over the kinds of technologies that make their way into healthcare systems. The paper draws on the international innovation policy scholarship and the lessons our research team learned throughout a 5-year fieldwork conducted in Quebec (Canada). Current policies support the development of technologies that capital investors identify as valuable, and which may not align with important health needs. The level of congruence between a given health technology-based venture and the mandate of venture capital is highly variable, explaining why some types of innovation may never come into existence. While venture capitalists' mandate and worldview are extraneous to healthcare, they shape health technologies in several, tangible ways. Clinical leaders and health policy scholars could play a more active role in innovation policy. Because certain types of technology are more likely than others to help tackle the intractable problems of healthcare systems, public policies should be equipped to promote those that address the needs of a growing elderly population, support patients who are afflicted by chronic diseases and reduce health disparities.

The unbearable lightness of citizens within public deliberation processes

There is a growing literature examining the involvement of citizens in health policymaking. While determining what form such involvement should take and who should participate is of particular interest to policymakers and researchers, the current ontological understanding of what a citizen is suffers from "lightness." This essay thus seeks to provide more depth by shedding light on the ways in which individuals define what "being" a citizen means for them and choose to embody or not such a role. Inspired by a four-year ethnographic study of a Canadian science/policy network in genetics, which integrated citizens into its operation, this paper provides four biographical sketches that portray the complexity and richness of what these individuals were "made of." We reflect on how they sought to make sense of their participation in the network by drawing on a repertoire of cultural, relational and cognitive resources and on their lived experience. Their capacity to "be" a participant and to be acknowledged as such by the others was shaped by their values and interests and by the contributions they sought to realise throughout their participation. Our discussion suggests that the quest for the "ordinary" citizen is misleading. Instead, acknowledging the sociological concreteness of citizenship and understanding how it may be embodied and exercised should be a key focus in public involvement theory and practice in health care.

How do medical device manufacturers' websites frame the value of health innovation? An empirical ethics analysis of five Canadian innovations

While every health care system stakeholder would seem to be concerned with obtaining the greatest value from a given technology, there is often a disconnect in the perception of value between a technology's promoters and those responsible for the ultimate decision as to whether or not to pay for it. Adopting an empirical ethics approach, this paper examines how five Canadian medical device manufacturers, via their websites, frame the corporate "value proposition" of their innovation and seek to respond to what they consider the key expectations of their customers. Our analysis shows that the manufacturers' framing strategies combine claims that relate to valuable socio-technical goals and features such as prevention, efficiency, sense of security, real-time feedback, ease of use and flexibility, all elements that likely resonate with a large spectrum of health care system stakeholders. The websites do not describe, however, how the innovations may impact health care delivery and tend to obfuscate the decisional trade-offs these innovations represent from a health care system perspective. Such framing strategies, we argue, tend to bolster physicians' and patients' expectations and provide a large set of stakeholders with powerful rhetorical tools that may influence the health policy arena. Because these strategies are difficult to counter given the paucity of evidence and its limited use in policymaking, establishing sound collective health care priorities will require solid critiques of how certain kinds of medical devices may provide a better (i.e., more valuable) response to health care needs when compared to others.

Marginal voices in the media coverage of controversial health interventions: how do they contribute to the public understanding of science?

While the media are a significant source of information for the public on science and technology, journalists are often accused of providing only a partial picture by neglecting the points of view of vulnerable stakeholders. This paper analyzes the press coverage of four controversial health interventions in order to uncover what voices are treated marginally in the media and what the relative contributions of these voices are to the stories being told. Our empirical study shows that: 1) patterns of source utilization vary depending on the health intervention and less dominant stakeholders are in fact represented; and 2) the use of marginal voices fills certain information gaps but the overall contribution of such voices to the controversies remains limited. In order to strengthen the media coverage of science and technology issues, we suggest that further research on journalistic practices: 1) move beyond the dichotomy between journalists and scientists, and 2) explore how different categories of readers appraise the meaning and relevance of media content.

Le phéochromocytome comme cause inhabituelle de choc cardiogénique

The authors reported a case involving a young patient with a cardiogenic shock associated to an acute pulmonary oedema. According to the seriousness of the shock, an external ventricular assist device (VAD) was initially inserted and replaced thereafter because of the cardiovascular instability, by an external pneumatic biventricular assist device. A cardiogenic shock induced by an acute adrenergic myocarditis due to a phaeochromocytoma was diagnosed. The patient was weaned from the VAD on day 84 and was scheduled for elective surgery of the phaeochromocytoma on day 93. The authors discussed the time of the surgery according to the anticoagulation therapy necessary to the VAD and the necessary caution taken if a cardiogenic shock appeared around surgery.

How place matters: unpacking technology and power in health and social care

The devolution of care into nontraditional community-based settings has led to a proliferation of sites for health and social care. Despite recent (re)formulations of 'evidence-based' approaches that stress the importance of optimizing interventions to best practice by taking into account the uniqueness of place, there is relatively little guidance in the literature and few attempts to systematically 'unpack' key dimensions of settings most relevant to policy, practice and research. In this paper, we explore how place matters for health and social care. In effect, we propose making place the lens through which to view practice, and not simply an interesting sideline focus. We focus specifically on (a) the emplacement of power relations in health and social care in and across settings; and (b) the pervasive (and often unrecognised) influence of technology on and in place (both 'mundane' and more visible 'high' technologies) as arguably among the most significant and pervasive (and often overlooked) dimensions of place pertinent to health and social care in both traditional (institutional) and nontraditional (community) settings. Drawing on diverse disciplinary literatures, we seek to make visible certain issues and bodies of work that health professionals may not be aware of, and which often remain inaccessible to practitioners and applied researchers on account of their density, complexity, and specialised terminology. In particular, drawing on the rich tradition of cultural studies, we advance the culture of place as a rubric for understanding the complex interrelationship between power, technology, culture, and place. Several fruitful avenues for place-sensitive research of health and social care practice (and its effects) are suggested.

[Epidemiology and diagnosis of respiratory syncitial virus in adults]

Introduction

Le virus respiratoire syncytial (VRS) est rarement recherché dans les infections respiratoires de l’adulte. Ce travail en étudie la fréquence et le diagnostic.

Méthodes

Trois enquêtes distinctes ont été menées chez des adultes atteints soit d’un syndrome pseudo-grippal, d’une infection respiratoire basse communautaire ou hospitalisés pour une pneumopathie infectieuse grave. La recherche du VRS a été faite par PCR dans tous les cas et comparée à la détection antigénique et la culture dans deux enquêtes.

Résultats

Le VRS est identifié chez 20 (11,7 %) des 170 adultes vaccinés contre la grippe atteints d’un syndrome pseudo-grippal. Dans 270 infections respiratoires basses communautaires sans signes de gravité on trouve un virus dans 86 (31,8 %) cas, dont 13 VRS (4,8 %) ; un virus est détecté dans 64 (36,7 %) des 164 bronchites aiguës : 11 VRS (6,3 %), 37 rhinovirus (21,3 %), 5 virus influenza A et B, et 12 autres virus ; dans les 60 bronchites chroniques surinfectées, il y a 9 rhinovirus (15 %), 2 virus parainfluenza 3 et aucun VRS ; dans les 21 pneumopathies infectieuses aiguës, on trouve 1 VRS, 1 virus influenza A et 2 rhinovirus, et dans les 11 cas d’infections respiratoires basses sur poumon pathologique, 1 VRS, 1 virus parainfluenza 3 et 4 rhinovirus ; il y a au total 19 infections bactériennes et virales associées. Enfin, dans les 51 pneumopathies infectieuses avec détresse respiratoire hospitalisées en réanimation, un virus est isolé dans 17 (33,3 %) cas : 3 VRS (5,8 %), 6 virus influenza A, 3 rhinovirus, 2 adénovirus, 2 herpes simplex et un CMV ; il y a 6 infections bactériennes associées dont 4 d’origine nosocomiale. Tous les patients infectés par le VRS sont âgés et présentent un facteur de risque respiratoire ou cardiaque.

Conclusions

Chez l’adulte le VRS est responsable de fréquents syndromes pseudo-grippaux et parfois d’infections respiratoires basses, qui peuvent être graves et qu’il faut penser à rechercher. La technique PCR est particulièrement efficace mais non disponible en routine.

Teleconsultation: rejected and emerging uses

OBJECTIVE

The aim of this paper is to analyse telemedicine as a new means to improve health care accessibility.

METHOD

A case study design was used to understand how medical specialists perceived, made sense of, and appropriated a teleconsultation system.

RESULTS AND CONCLUSIONS

The technology was used neither in the manner nor to the extent anticipated by its designers. A fundamental modification to the traditional medical consultation process has emerged. Unable to be used as a substitute to the traditional medical consultation process, the teleconsultation system imposes a greater burden on the shoulders of participating physicians who, after a few trials, returned to their traditional mode of practice.

The theory of use behind telemedicine: how compatible with physicians' clinical routines?

Since the early 1990s, telemedicine, or the use of information technology to support the delivery of health care from a distance, has increasingly gained the support of clinicians, administrators and policymakers across industrialised countries. However, the "theory of use" behind telemedicine-its rationale and the manner in which clinicians are expected to use it in their daily activities--has been only marginally investigated. In this paper we present the results of a qualitative study which examines the theory of use behind teleconsultation from the viewpoint of physicians (n = 37) in six specialities, practising in Quebec (Canada) hospitals. We employ Giddens' Structuration Theory (1984) to analyse the views, communications needs and referral strategies of physicians. Two questions are explored: (1) To what extent can teleconsultation be integrated into the routines of diverse medical specialities'? and (2) Why and how might clinicians use this technology? Our research indicates that specialities relying on either thorough physical examinations or specialised investigative techniques are unlikely to restructure their work routines to accommodate teleconsultation, which they view as limited. Specialities that primarily exploit images or numerical data tend to perceive teleconsultation as more useful. The perceived enabling properties of teleconsultation increase as a function of the distance the patient would have to travel to be seen directly by a consultant. The constraining properties are linked to the type of information transmitted, since physicians believe that only objective data can be safely consulted from a distance, whereas relying on the remote physician's interpretation of subjective information is deemed inappropriate. We thus conclude that the development of teleconsultation should be consolidated around applications whose theory of use is compatible with existing clinical routines, or offers opportunities to restructure clinical work according to the needs of providers and remote communities.

[Severe intoxication with cardiotoxic drugs: value of emergency percutaneous cardiocirculatory assistance]

Acute severe self-administration of an overdose of betablockers, calcium antagonists or antiarrhythmic drugs is rare but carries a mortality of 10-15%. Between May 1997 and March 2000, 6 patients with an average age of 34 years (range 17-55 years) had a cardiac arrest on admission requiring emergency cardiac massage and emergency intubation with ventilatory assistance following massive ingestion of cardiotoxic drugs. Echocardiography confirmed complete biventricular akinesia. The surgical team implanted a cardiovascular assist device (ECMO: Extra Corporeal Membrane Oxygenation) by the femoral approach with pre-heparinated percutaneous cannula. The first two patients died of multi-organ failure due to a delay in the installation of the assistance. The 4 other patients survived without sequellae or recurrences. The average time on ECMO was 59.25 +/- 2 hours (range 48-71 hours). The early recognition of the indication for ECMO was one of the most important predictive factors for morbidity and mortality. The strategy of patient management should be determined in the emergency room: in cases of cardiocirculatory arrest resistant to symptomatic treatment (stomach washout, intravenous fluids, isoprenaline, inotropic agents) an echocardiogram should be obtained and the cardiac surgical team alerted to the problem. The introduction of pre-heparinated circuits, percutaneous cannula and peripheral shunts has widened the indications, efficacy (detoxification, restoration of peripheral tissue perfusion) and accessibility to this material, while limiting its duration. The collaboration of experienced multidisciplinary teams (emergency room staff, cardiologists, anaesthetists and surgeons) should optimise the timing of implantation and the monitoring of these systems and improve the results of resuscitation of these patients.

[How to favor clinical research in pedopsychiatry? An experience of a cooperative action-research.]

Clinical evaluative research are far too few. In this article, the authors describe a research process likely to favor its multiplication. They report on a case study of a process resembling a cooperative action-research led by a group of clinicians in pedopsychiatry. With the results and in the light of caracteristics of action-research, they explain why and how this group of clinicians has succeeded in establishing a research process. The lessons drawned from this experience are numerous. The authors conclude by proposing a cooperative action-research as a model that all clinicians could apply to a clinical study.

Technology assessment and the sociopolitics of health technologies

In a growing number of countries, health technology assessment (HTA) has come to be seen as a vital component in policy making. Even though the assessment of the social, political, and ethical aspects of health technology is listed as one of its main objectives, in practice, the integration of such dimensions into HTA remains limited. Recent social scientific research on the inherently political nature of technology strongly supports such a comprehensive approach. The growing claims by and on behalf of consumer groups also suggest that HTA should be informed by a broader set of perspectives. Using the example of the cochlear implant in children, this essay compares the professed objectives of HTA with typical practice and explores possible explanations for the discrepancies observed. A second example, home telemonitoring for elderly persons, demonstrates how the types of evidence considered by HTA and the process through which assessments are produced may be reconsidered. We argue for the formal integration of the sociopolitical dimensions of health care technologies into assessments. The ability of HTA to more fully address important issues from a public policy point of view will increase by making explicit the sociopolitical nature of health care technologies.

Health technology assessment and the regulation of medical devices and procedures in Quebec. Synergy, collusion, or collision?

In this paper, we discuss the complex relationship between health technology assessment (HTA) and the regulation of medical devices and procedures. The relationship is first examined through a conceptual framework describing the itinerary from research to three levels of policy making: micro (standards of medical practice), meso (institutional rules), and macro (health policies). Four reports from the Quebec Health Technology Assessment Council (CETS) are used to illustrate how HTA activities can influence the regulatory mechanisms operating at each decision-making level. We then discuss the skillful balancing act required from HTA agencies to constantly negotiate the right distance from the regulatory process at which to operate. We propose that HTA agencies should not be incorporated into any regulatory, auditing, or monitoring process. Finally, the relationship between health technology assessment and health care reform is discussed. It is suggested that HTA activities will contribute most during the data-driven preparation and consolidation phases of a reform process. The fast pace of events and the political turmoil characteristic of the implementation phase provide a less receptive environment for HTA contributions.

Telehealth: passing fad or lasting benefits?

Advocates of telehealth argue that the delivery of health services by means of communications technologies is both feasible and desirable. Nevertheless, the benefits of telehealth, due to the variety of its applications and their uneven development, are not self-evident. The goal of this paper is to reflect on the processes by which telehealth applications do or do not contribute to the delivery of health services. We propose a framework structuring a preliminary analysis of the match between needs and the possibilities offered by telehealth. Four mechanisms of expected benefits are discussed: 1) decreasing patient transfers; 2) decreasing trips by providers and patients; 3) meeting the needs of underserved populations; and 4) building providers' and patients' knowledge and reducing rural isolation. We conclude by stressing that the participation of providers is crucial, both in the research on telehealth and in the steering of its evolution.

Theory of use behind telehealth applications

A variety of telehealth applications have been implemented throughout the industrialized world. Given that telehealth has yet to become routine in the practices of physicians, the impact of such applications on health care management remains difficult to identify. Only by becoming integrated into the 'normal practice' of clinicians can telehealth facilitate smooth communications in health care delivery processes. In this paper we demonstrate the importance of developing a 'theory of use', describing how clinicians are expected to use teleconsultation in their daily activities. By employing Giddens' Structuration Theory, we can develop a clear vision of the utilization of telehealth, and a better framework with which to assess its added value for health care delivery. We illustrate this claim by referring to our research on the Quebec Inter-Regional Telemedicine Network. In this study we compare the 'theory of use' behind the telemedicine network with the perceptions of physicians regarding their needs in terms of communications and access to expert advice. The breach between the theory and the perceptions of physicians may help to explain how the utilization of telehealth could be enhanced, and how new and sustainable routines for its integration into the health care system might be created.

[Public health professionals' perceptions regarding two dimensions of health promotion: the ecological approach and community participation]

The aim of this paper is to explore public health professionals' perceptions regarding two dimensions of the new health promotion movement: the ecological approach and the principle of community participation. Data were collected by focus-groups of public health professionals (n = 22) in one Public Health Directorate in Québec. Results indicate a fair degree of integration of these two dimensions into the respondents' professional practice. However, limitations related to the work environment and to the theoretical underpinnings of these two components might impede the respondents' ability to integrate them into their practice.

The computer based patient record: a strategic issue in process innovation

Reengineering of the workplace through Information Technology is an important strategic issue for today's hospitals. The computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. This study investigates a CPR project aimed at allowing physicians and nurses to work in a completely electronic environment. The focus of our analysis was the patient nursing care process. The rationale behind the introduction of this technology was based on its alleged capability to both enhance quality of care and control costs. This is done by better managing the flow of information within the organization and by introducing mechanisms such as the timeless and spaceless organization of the work place, de-localization, and automation of work processes. The present case study analyzed the implementation of a large CPR project ($45 million U.S.) conducted in four hospitals in joint venture with two computer firms. The computerized system had to be withdrawn because of boycotts from both the medical and nursing personnel. User-resistance was not the problem. Despite its failure, this project was a good opportunity to understand better the intricate complexity of introducing technology in professional work where the usefulness of information is short lived and where it is difficult to predetermine the relevancy of information. Profound misconceptions in achieving a tighter fit (synchronization) between care processes and information processes were the main problems.

The computer-based patient record challenges towards timeless and spaceless medical practice

Although computerization is increasingly advocated as a means for hospitals to enhance quality of care and control costs, few studies have evaluated its impact on the day-to-day organization of medical work. This study investigated a large Computerized Patient Record (CPR) project ($50 million U.S.) aimed at allowing physicians to work in a completely electronic record environment. The present multiple-case study analyzed the implementation of this project conducted in four hospitals. Our results show the intricate complexity of introducing the CPR in medical work. Profound obstructions to the achievement of a tighter synchronization between the care and information processes were the main problems. The presence of multiple information systems in one (Communication, Decision Support, and Archival record keeping) was overlooked. It introduced several misconceptions in the meaning and codification of clinical information that were then torn apart between information richness to sustain clinical decisions and concision to sustain care coordination.