Social and ethical values in eHealth policy

Realising the benefits of eHealth is not simply a technological endeavour, a new report into the social and ethical implications of eHealth policy in Ireland by the Oireachtas’ Library and Research Service states.

Unlocking the potential of eHealth solutions requires “careful attention to the interdependencies between people, process and technology”, the report, written by Tim Jacquemard, Royal College of Surgeons in Ireland and Science Foundation Ireland researcher-in-residence, states. Published in March 2021, the report says that eHealth solutions are “often complex, large-scale projects with significant economic, social and ethical implications” and that “a failure to address these interdependencies can lead to undesirable outcomes, such as privacy breaches, wasted monies and project collapse”.

Through its examination of Irish eHealth legislation, its implementation by governmental and non-governmental bodies and case studies such as the Covid Tracker App, the report identified 10 policy issues for eHealth in Ireland.

1. Irish policy and debate consider eHealth to be a critical enabler of healthcare reform

   Activity around eHealth in Ireland is constantly growing, and public debate “ascribe[s] eHealth the ability to transform the Irish healthcare into a more patient-centric, integrated and cost-effective system. The Programme for Government, Sláintecare, and the National Development Plan all make specific mention of eHealth, while the past 10 years have seen the partial rollout of a number of initiatives, such as the individual health identifier and ePrescribing. Other national projects which will provide the basis of national eHealth in the decades to come, such as the national health record, are said to be “under development”.

2. A failure to identify and address social and ethical implications can impact the success of eHealth technology

   The report states that among the factors that determine the success of successful eHealth applications are “the social and ethical values of stakeholders, their organisations, and the cultural and political context”, meaning that the social, political and ethical values that are important in the Irish context must be factored in when designing these applications. A failure to do so “may lead to public backlash, lost investments or suboptimal functioning of the technology”. The social and ethical implications of eHealth “can be considered at the earliest stage of technology development” and “can help guide the design, development, implementation, and use of the technology”, the report states.

   “The research performed by Jacquemard ‘found no systematic approaches in Irish policy to address the ethical or social implications of eHealth’. He suggests that either the HSE or HIQA would be well-equipped to lead in this area.”

3. eHealth offers many ethical and social opportunities and challenges

   The report identified seven clusters of ethical and social challenges and opportunities in relation to eHealth: privacy; equality; human relationships; patient empowerment and vendor relationships; benefit and risks; responsibility; and transparency and trust. All seven clusters “include both opportunities to achieve socially and ethically desirable outcomes as well as challenges to avoid undesirable outcomes” with identification of benefits and risks critical to the success of these projects.

4. This research found no systematic approaches to address ethical and social implications of eHealth within Ireland

   Worryingly, the research performed by Jacquemard “found no systematic approaches in Irish policy to address the ethical or social implications of eHealth”. He suggests that either the HSE or HIQA would be well-equipped to lead in this area.

5. Ethical values are not explicitly mentioned in Irish policy on eHealth

   The research also found there to be no explicit mention of ethical values in Irish eHealth policies, with such ethical values left to “only appear implicit within Irish policy and debates around eHealth”.

6. Irish policy and debate emphasise benefits for healthcare improvement

   The benefits of eHealth discussed in Irish policy fit with the “quadruple aim” method of improving healthcare by improving individual experience of care, improving the health of populations, reducing the per capita cost of care for populations and improving the clinician experience of care. The discussion on eHealth and health improvements in Ireland “aligns closely with a more contemporary understanding of health as a person’s ability to adapt and to self-manage”. Benefits for clinicians are said to be mentioned less frequently.

7. Other clusters of social and ethical opportunities are mentioned less frequently in policy documents and debates on eHealth

   While the report says that the issues covered in the Irish debate around eHealth are pertinent, it also states that “other relevant benefits exist”. The questions Jacquemard suggests to be considered are: “how can eHealth improve the work experience of clinicians?”; “how can technology improve the relationship between clinician and patient?” and “how can eHealth make communication more secure?”

8. Irish policy and debate emphasise challenges associated with privacy and data protection

   Perhaps understandably given what has transpired since the publication of the report in March, Jacquemard says “the challenges mentioned concern mostly privacy and data protection” in the Irish context of eHealth discussions, unlike at EU level, where the challenges of eHealth itself are the focus. The report warns that “reducing ethical and social concerns to privacy and data protection can lead to suboptimal technology, as eHealth presents a wider range of ethical challenges”.

9. Many of the social and ethical opportunities in Irish policy leave room for interpretation

   The report states that the “ethically and socially relevant benefits and challenges mentioned in policy are general aims and objectives”, which means that the “high level of abstraction leaves the ethical and social opportunities open to interpretation”. One example cited is that the eHealth Strategy for Ireland makes mention of the digital divide but does not elaborate on how eHealth might help to bridge that divide, and that the divide is not mentioned in the eHealth section of Sláintecare. Questions in this are to be considered, Jacquemard suggests, are: “Which parts of the population will gain better access and who will benefit the most?”; and “how will people who lack the requisite digital and health literacy skills be supported?”

10. Irish eHealth policy focuses mainly on policy for health services devices

    Irish “eHealth policy is focused on health service reform: the technologies emphasised in the policies reflect this focus on service reform”, with the technologies discussed in the Irish context, such as electronic health records, ePortals, telehealth, and ePrescribing, aimed at improving relations between health service providers and patients. The report notes that EU health policies “tend to focus on consumer technologies as well, such as mobile health, social media, and wearable devices”. With consumer technologies now so ubiquitous, the report states that the “HSE may increasingly integrate consumer apps, for example videoconferencing for telehealth”. Healthcare organisations and consumers need protection against inadequate technology, Jacquemard says, noting that “apps may contain disinformation, lack security updates, or show poor regulatory compliance”.