An Open Question on Moral Authority and Healthcare IT

I recently had the chance to observe a relative's care in a small community hospital.

This was a hospital that, in my relative's last several days there before going back to a nursing home for rehab, went live with a major vendor CPOE.

Just by passing the nursing station/doctor's charting room on my relative's floor and opening my eyes and ears, I saw doctors and nurses struggling to take care of patients while "getting the bugs out of the system."

They had had received some classroom "training" in a static environment, but it was clear they were learning about a lot of "gotcha's" and unanticipated glitches in vivo.

The fact of problems were predictable; I told several of my relative's physicians about my work in studying these issues.

There was some skepticism (maybe in my nearly being in tears about my relative, I came off as a bit melodramatic). However, several later told me they "now knew what I was talking about" upon my relative's discharge, just several days into the go-live.

One story I overheard during go-live especially sticks out in my mind.

A newly-admitted patient who needed urgent heparinization did not receive the medication promptly. The patient's physician could not order it, and could not enter the required weight needed to order it, due to some type of 'glitch' or system malfunction. Physicians found no way to override, despite calls to the help desk, attempts by on site IT people and users from the parent hospital, etc.

In the end, the pharmacist simply provided the med using a weight estimate despite no "official" order having been entered into CPOE. I heard that the delay was on the order of "several hours."

Clearly, both technology and people issues were involved ... but I assure the reader, injured or dead patients really don't care exactly how their injury occurred, after the fact (other than in litigation, which doesn't fix the damage or remediate the suffering).

Here, then, is my question:

Where does the moral authority come from to subject live, unsuspecting, uninformed patients to the type of risks the patient whose heparin was delayed was subject to?

What right did the hospital have to NOT inform this patient before admission that a new critical CPOE system was going "live" that day, and that the patient could consider going to another hospital a few miles down the road instead that had no such potential problems?

From the Belmont Report (also see http://ohsr.od.nih.gov/guidelines/belmont.html ), the six fundamental ethical principles for using any human subjects for research are:

• (1) Respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent;
• (2) Beneficence: maximizing benefits for the research project while minimizing risks to the research subjects; and
• (3) Justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly (the fair distribution of costs and benefits to potential research participants.)
• (4) Fidelity: fairness and equality.
• (5) Non-maleficence: Do no harm.
• (6) Veracity: Be truthful, no deception.

I would like a straight, unspun answer to this simple question:

On the basis of Belmont Report and other medical ethics regulations, where does the moral authority come from for hospitals to put patients through such risks without informing them ahead of time and offering them an opt-out, even if only the continued use of paper in their care?

I have passed this question on to major American Medical Informatics Association mailing lists and await replies.

-- SS