Ethics, Technology and the Future of Aging

Aging Services of California May 5, 2010

Michael A. Gillette, Ph.D. (434)384-5322 mgillette@bsvinc.com http://www.bsvinc.com

Introduction

Methods of Doing Ethics

Method In Ethics

Casuistry
THEORY

PRINCIPLES

EASY CASES

HARD CASE

EASY CASES

The Ethics of Patient Refusal

The Limits of Provider Support

Optimal Care Sub-Optimal/Super-Standard Care Sub-Standard Care

Staff never have an obligation to commit malpractice

Facebook Ethics

Facebook Ethics
Its In The Public Domain
Mr. G is a resident of independent living who resides in a cottage at local facility that offers a complete continuum of care. Mr. G recently approached the facility chaplain and indicated that he was worried about Mr. S, who also lives in independent living. Mr. G is worried that Mr. S might engage in self-injurious behavior, and cites Mr. Ss Facebook page as the source of his concern. How should the chaplain respond?

Facebook Ethics
Questions
Would it be ethical for the chaplain to examine Mr. Ss Facebook page in response to Mr. Gs concern? Finding information on Facebook to be useful, would it be ethical for the chaplain to look up all the residents at the facility to see if they have postings? How should information from Facebook be used once it is obtained? Would the case be different if the resident lived in assisted living? Skilled Care? Would the case be different if a therapist or physician were to access Facebook?

Facebook Ethics
Possible Positions
Public postings on My Space contain public domain information and are thus fair game. It is not unethical to view clients postings Searching My Space pages is not a professional activity and is ethically equivalent to surveilling clients in public. This behavior is unethical. Acting on information received within one clients therapeutic exchange to confront another client constitutes an unethical breach of confidentiality. Checking My Space would be ethical if clients are informed of that possibility at the onset of services.

Policy

Electronic Communication
Policy Considerations
1. We recommend that postings to MySpace, Facebook or other similar electronic social networks constitutes a public display of information. Therefore, we believe that it is not intrinsically unethical for staff to view any material that a client posts without restricting access. Viewing such material is ethically equivalent to observing public behavior in the community, and is not, therefore, unethical.

Electronic Communication
Policy Considerations
2. We recommend that while there is no intrinsic ethical problem with witnessing publicly observable behavior, the effort that one expends to locate the information and the intent behind such efforts could create clinical problems in the therapeutic relationship. For instance, if a staff member happens to be at the mall one evening and sees a client engaging in dangerous behavior, it does not seem that the staff person has done anything wrong and he/she might, based on clinical judgment, raise the issue in a therapeutic encounter. On the other hand, if a staff member goes out of his/her way to find a client at the mall, and then witnesses dangerous behavior, the disclosure of this information to the client could compromise therapeutic trust. We believe that tracking down MySpace postings and then discussing them in therapy could have the same counter-therapeutic aspects as following a client to the mall and then confronting him/her about observed behavior. While witnessing the activity or seeing the information is not intrinsically wrong, the manner in which the staff member locates the information and then uses it could be clinically damaging. We recommend that careful clinical judgment, similar to that already used regarding information from non-electronic sources, should also apply to information obtained from the internet.

Electronic Communication
Policy Considerations
3. We recommend that staff members do not have an ethical obligation to disclose to all clients at the outset of services that they might, under appropriate circumstances, access electronic social networking sites. We can imagine a staff member responding to a threat of harm in an appropriate way, or accidentally accessing a clients site, and such activity would not be unethical. We do not believe that staff has an obligation to notify all clients universally that such access might take place. Decisions to disclose the risk of publicly posting information should be made on the basis of the clinical situation of each client.

Electronic Communication
Policy Considerations
4. We recommend that staff should be aware that in contemporary society, risks of harm may develop secondary to internet use. Individuals may put themselves at risk by inappropriately disclosing information on the internet, and individuals may become pathologically dependent on internet use. These risks are real, and we recommend that they should be managed similarly to approaches to substance abuse or sexual activity. Clinicians need to be alert to individual risks factors regarding internet safety and should deal with this as clinically indicated.

Electronic Communication
Policy Considerations
5. We recommend that staff members should also be aware that their own postings on electronic social networking sites could compromise their roles as providers. Certain types of postings could create dual relationships with clients, impair therapeutic authority, and negatively impact collegial dealings. For these reasons, staff members must also understand the public nature of making postings and they should refrain from activity that interferes with their ability to satisfy their delineated employment functions.

Electronic Communication
Policy Considerations
6. In summary, we recommend that our attitudes concerning electronic media should be very similar to existing attitudes regarding the observation of, response to, and clinical relevance of any other publicly observable behavior. The internet poses new opportunities for interaction, but we believe that, at least with regard to this topic, it does not pose any novel ethical challenges. We suggest that ethical attitudes toward the internet should be normalized to attitudes regarding telephonic and paper correspondence and the revelation of information by any other more traditional means.

Email

Email Ethics
Conceptual Expectations
Instantaneous Delivery Immediate Response Context and Tone Casual Conversation vs. Formal Correspondence Texts and Tweets Professional Services, Counseling Online

Electronic Communication
Email
1. We recommend that the current use of email by staff to engage in activities like scheduling is not ethically problematic and that it should continue or increase. We recommend that any communication that does not discuss client-specific information and does not include client identifiers is a reasonable use of email that should not be restricted when relevant to job performance (i.e. the agency may maintain an appropriate use policy that limits non-professional use of the agencys computer system, but it should encourage extensive use of this technology when confidential information is not being transferred).

Electronic Communication
Email
2. We recommend that until clear standards of use have been developed, staff should not solicit email contact with clients. On this basis, we recommend that email addresses should not currently be included on staff business cards.

Electronic Communication
Email
3. We recommend that clients be informed in explicit terms that the agency does not guarantee the reliability or speed of email communications. Clients should be instructed to consider using alternate communication tools if they do not get a response to email in a reasonable period of time. This instruction should also apply to standard communications such as paper mail and voice mail. If a client does not receive a response, he/she should consider making a communication effort by alternate means.

Electronic Communication
Email
4. We recommend that clients should be informed in explicit terms that the agency does not recommend that email or voicemail are appropriate methods of communication in a crisis situation. Clients must be informed of the availability of emergency phone numbers so they can access people immediately. Staff should continue to put emergency contact information reminders on their own voicemail systems.

Electronic Communication
Email
5. We recognize that many individuals treat email more like verbal conversation than written correspondence. Therefore, staff and clients must be made aware of the fact that if they choose to use electronic means for communication, those communications will not be considered differently than paper correspondence. All involved parties should be made aware of the fact that copies of emails may be printed out by the recipient and included in formal documentation. We recommend that clients be informed that all written, oral, and electronic correspondence which the agency receives is considered agency property and may be reproduced or saved as professional standards of care may require.

Electronic Communication
Email
6. We recommend that sensitive information received by electronic means should be considered a protected part of a clients record. Copies may be printed or electronically transferred for inclusion in the chart, but that information must only be accessed on a need to know basis. Re-release or blind copying of emails must be considered under the same restrictions, and must only be allowed when there is a clinical need to know and the recipient of the information has legitimate access to the clients record.

Electronic Communication
Email
7. We recommend that the agency create an email consent document to be signed by all clients who wish to interact with the agency or its staff via email. This document should explicitly state the limitations of email, and indicate that email will only be sent to the email addresses that are listed by the client. This document should also indicate that security and confidentiality of the those listed email addresses is the responsibility of the client, and that by signing this document the client authorizes the agency and its staff to send sensitive information to the specified email addresses.

Electronic Communication
Email
8. We recommend that staff members have the prerogative to determine the types and amounts of information that may appropriately be communicated via voicemail, faxes, and email. Staff should exercise their option to refuse to discuss certain topics by specific means and to divert the conversation to other more appropriate avenues when necessary.

Electronic Charting

Documentation
Ethical Issues
Accuracy Honesty Relevancy Completeness Confidentiality

Electronic Record Keeping

Forgery
Is it ethical/legal/proper for one staff member to document services rendered by another clinician? May a staff person claim to have provided services that he/she did not provide? May a staff person sign another persons name to clinical notes?

Electronic Record Keeping

But The Work Is Done
Staff person A left the agency without completing all of the paperwork on some of his clients. In order to avoid the paperwork involved in documenting a change in providers, Mr. As supervisor contacted medical records and asked for Staff person As password. The supervisor wanted to sign on as the staff person to complete the documentation and lock down the record for billing.

Electronic Record Keeping

Job Responsibilities
Would it ever be appropriate to ask a fellow staff member to photocopy notes out of a chart, place them into another file, and then sign your name to indicate that you had written the notes from scratch?

Electronic Record Keeping

Cut And Paste
Therapist B has been working with a client for over a year and much of the service plan is repeated month to month. Therapist B requested that clerical staff open the next 90-day treatment plan for a client on our electronic client record by copying the previous treatment plan into the system.

Electronic Record Keeping

The Check Is In The Mail
Would it be ethical, on April 5th, to write a check to the electric company that was due on April 1st and to date the check as having been written on March 15th? If the electric company called and asked whether you had mailed the check, would it be ethical to say that you had done so several weeks prior and that the check must be lost in the mail?

Electronic Record Keeping

Electronic Honesty
Clinician C documented that she closed an assignment for one of her clients on February 5th. The documentation indicated that an assessment was performed on that date and that it was documented on that date. However, the time stamp on electronic file indicates that the activity took place on March 7th.

Electronic Record Keeping

Thats Just Fraud
Is it ever permissible to bill insurance companies for services that have not yet been provided?

Electronic Record Keeping

First Things First
Clinician D opened the progress notes for three clients and completed the billing portion at 9:00am for each one of them. By doing things this way, Clinician D was able to save time. At the end of business that day Clinician D went back to enter his notes subsequent to a 2:00pm session with one client and a 3:30pm session with another client. The next morning, after a 10:30am appointment, Clinician D entered the note on the third client. The time stamp on the file shows that a bill was generated at 9:00am on day one when the services had not even been provided until some time later. The time stamp on the service shows the discrepancy between time and date of billing and time and date of service.

Electronic Record Keeping

Wheres The Shredder?
Are there any situations in which, rather than correcting or augmenting documentation, it would be appropriate to destroy notes that were previously written? Can we cancel discharge orders after they have been documented and executed?

Electronic Record Keeping

Lets Pretend That Never Happened
Clinician E wrote a discharge summary for one of his clients whose services were then discontinued for two weeks. The client presented for new services and rather than engaging in a new intake, Clinician E attempted to locate the previous discharge summary in the electronic record and delete it.