Course:PSYC537/2010WT1/Vignette2

VIGNETTE 2

You are a psychologist working in a hospital as part of a multidisciplinary treatment team for adolescents. The team members are housed in different units, some at different hospitals, and meeting as a group to conduct rounds has proven impossible. One of the physicians begins sending detailed emails regarding some of the more difficult patients to the team to coordinate care. The practice seems to be effective and there are fewer instances of patients attempting suicide or acting out on the unit. What would you do?

STEP 1: Who are the people potentially affected by decision?

- all the team members, including yourself

- the adolescents on the unit who are being discussed (and potentially all the adolescents being treated by the multidisciplinary team).

- the hospital as an organizational body

- the individuals who have consented to treatment on behalf of the adolescents (AH)

STEP 2: What are the relevant ethical issues/laws? Which ethical values/laws are in conflict?

There is a conflict between Confidentiality and Responsible Caring.

1)Within confidentiality the CPBC code of conduct allows for sharing of information with professionals so long as the registrant ensures all receiving the informaiton are aware of its confidential nature and as long as the client has been informed in advance (6.14).

2)Also relevant under confidentiality is 14.3 in CPBC code of conduct which requires all information prepared, kept or maintained electronically is reasonably secure from loss, tampering, interference, or unauthorized use or access.

3)Included in responsible caring however in the CPA code of ethics is the idea of "maximizing benefit" which seems to be a result of the emails being sent within the team. Specifically II.I8 states "Provide services that are coordinated over time and with other service providers, in order to avoid duplication or working at cross purposes" (HM)

STEP 3: How do personal biases, stresses or self-interest affect my choice of action? You may have worked with interdisciplinary teams in the past and been frustrated by how long it takes to come to decisions, so the speed and effectiveness of communicating through email may be a welcome relief. You may be under time constraints and are unable to make many of the meetings that had been scheduled up to this point, so this current situation is very convenient.

On the other hand, you may be uncomfortable communicating through email. This could be because of potential complications that have arisen due to privacy (i.e., you've had information leaked in the past) or possibly because you find that you cannot communicate as well over email as you do in person. Similarly, your own views on privacy and confidentiality will come into play here.

Additionally, you may be pleased with the increased success of these actions, with less patients committing suicide and better overall behaviour, so you may want to continue doing things the way they are because it looks good on your treatment, and why would you want to change things? You are able to treat your patients more effectively, so this is good for you overall. (KA)

STEP 4: Consult with colleagues.

STEP 5: Develop alternative courses of action.

option #1- Decide to participate in the email communication.

option #2- Opt out of participating in the email communication and limit communication to only people who are in your hospital who you can discuss with face to face.

option #3- Establish an email account that everyone in the treatment team has the password to and have everyone create their emails about the relevant issues in that account addressed to only that account.

option #4- Use emails only to arrange conference calls. (AA)

option # 5- Request and insist that the team stop communicating patient information via email (explaining reasons, i.e., confidentiality and information security).

option # 6- Have everyone in the team send patient information through password-locked files (instead of directly written in the email - separating information content from direct online access). Using the same password across the team. Make sure the password is sent separately from patient information messages. (JK)

STEP 6: Analyze likely short-term, ongoing and long term risks and benefits of each. option #1- Decide to participate in the email communication.

Risks: Information may be leaked to third parties who are not authorized to receive confidential patient information. This leak may continue from one party to another and escalate until the information becomes readily accessible on the internet. Patient confidentiality is therefore compromised entirely. If the patients find out that their confidentiality has not been upheld, they may be reluctant in the future to seek necessary health care. For participating in the email communication, you, as the psychologist, may face disciplinary action from various governing bodies and legal action from clients. The hospital as a whole may also be castigated and sued because of the email exchange between members of the multidisciplinary team.

Benefit: You will have input in the discussion that is taking place over email and have an opportunity to make significant contributions to the clients’ progress. (SC)

option #2 - do not participate in email exchanges; only communicate face-to-face. Risks: The client may receive less coordinated care because you are only communicating your treatment progress and decisions to individuals within your hospital, while other providers may also need that information. You may still be open to liability from violating privacy regulations, even without participating, because you knew about the violation but did not report it or make an effort to keep others from engaging in it. Others on the team may be upset that you are not communicating with them about the client.

Benefits: Potentially more accurate information transmission between you and others on the team, as sometimes email communications can miss nuances that can be communicated well face-to-face. Reduced risk of violation of privacy by making your actions compliant with regulations, laws, and ethical standards. (SV)

option #3 - limit emails to one jointly-used account. Risks: Because the information is stored in a separate place, members of the team may be less likely to check the account for information than their own email, delaying dissemination of client information. Depending on how well individuals protect the joint account, the information could still be compromised (either by someone gaining access to the password, or information being leaked through hacking into the system). Some team members might refuse to switch over to the new system. Might be difficult to know who is writing a particular email about the client because everyone is using the same account. If a team member leaves the team, all of the account information would have to be changed to prevent that person from continuing to access the individuals' records. May still be open to legal action for violating privacy regulations, depending on the security of the system being used.

Benefits: Somewhat greater protection of privacy, as the client's information is only available through one account, as opposed to several. Allows for greater intra-team communication and continuity of care between providers. Ensures that information about the client does not get "lost in the shuffle" of other work or personal email. Allows for greater continuity of care. (SV)

Option #4: - Use emails only to arrange conference calls. Risks: As mentioned in the vignette, team members are housed in various units in hospitals or different hospitals, most of them are likely to have very different work schedules. Practically speaking, it might be extremely difficult to arrange conference calls with all or most of the members present. In addition, depending on the internet security, the information exchanged over conference calls could still be compromised, for instance, when someone gains access to member's chat account or chat history. Also, conference calls are not ideal for exchange of patient profiles, assessment reports and lengthy test results, in which case, conference call is not a substitute of emails as a mean of information transmission. We also need to be aware of the settings in which information is exchanged over conference calls. Due to the relatively informal nature of conference calls compared to traditional meetings, some practitioners might call from their home or in other public settings that potentially pose a threat to patient confidentiality.

Benefits: Conference calls allow practitioners of different units to engage in "face-to-face" discussions about the cases from their offices, without having to commute. It also offers somewhat greater protection of privacy, since no written document is being exchanged on the internet.(CC)

STEP 7: Choose course of action after conscientious application of principles. The most promising actions appear to be to option #6 and #4, depending on the particular circumstance and the type of client information that is being transmitted among the practitioners. Patient confidentiality holds paramount importance in clinical practices and provision of services. Practitioners' primary duty is to ensure that patient information is being securely stored and protected. We simply cannot afford any slight chance of patient information being stolen or hacked. If a (verbal) discussion is deemed necessary among team members, conference calls might be a good idea since it offers relatively higher protection of privacy over regular email exchanges. When written documents are being exchanged, we could send them through password-locked files, which help to prevent potential breaches of patient confidentiality. Changing the password regularly to make sure that only people who are still involved in the coordinated care would access the files. The key consideration in making this decision is that we try our best to maximize the therapeutic benefits for our patients (fulfilling the principle of responsible caring) while at the same time offering the maximum protection of patient confidentiality. (CC)

STEP 8: Act with commitment to assume responsibility for consequences.

STEP 9: Evaluate results of course of action.

STEP 10: Assume responsibility for consequences, including corrections or re-entry into decision making process if still unresolved.

STEP 11: Take action, as warranted, to prevent future occurrences.

When a multidisciplinary treatment team first forms, have members meet to discuss methods of communication. Whether that meeting be in person, by phone conference or by email. This initial chain of emails or communication should not contain any information pertaining to specific patients, but rather just discuss the matter of team communication. Discuss the ethical issues at hand (i.e., some non-psychologists particularly may not be aware of the issues). Once an appropriate decision is made about communication and confidentiality, including proper means of protecting the information (hard-copy or electronically) – perhaps by password protection (in which case, the password should be indicated in this first series of communications, separately from any patient information), have all members agree to follow the method chosen, as well as any new members that may be added to the team along the way. (JK)

I agree with Janet that holding meetings to discuss appropriate forms of communication would be an effective preventative measure. Furthermore, it may be beneficial if the clients are involved in this process of choosing appropriate communication methods. Members of the multidisciplinary team can ask the clients to indicate which communication methods are acceptable to them. I think it is valuable to obtain input from the clients regarding this matter, since after all, it is their information that is being exchanged between team members. Furthermore, during the informed consent process, the healthcare providers should list out all the ways that team members will use to communicate patient information to each other so that each client can evaluate, given this information, whether they want to proceed with treatment.

If the team members had a choice as to whether to take these adolescents on as clients, it may have been helpful if they were more realistic about their availability from the beginning. Before agreeing to be these clients’ caregiver, each team member should carefully assess their current work load to determine whether they have enough time to provide responsible care to additional clients, keeping in mind that caring for these adolescent clients will entail spending time travelling to different units and hospitals to conduct rounds on top of the time spent in treatment. Patient confidentiality should not be compromised as a result of the busy schedules of the caregivers. If a caregiver does not think that he or she has the time to commit to another client, the ethical decision is to refer the case to someone who can.

If, instead, the hospital is responsible for case assignment in this scenario, it should put its best effort into assigning this group of adolescent clients to a team of healthcare providers that belong to the same hospital, to make communication between team members easier. This, however, may not be possible due to external circumstances, such as the hospital’s budget and staff availability. (SC)