How has technology affected your life in the past 20 years? What effects have been improvements? What affects have created challenges?
What are technology companies' ethical responsibilities to society?
These are big questions, but they need to be asked as we live in a time where technology is integrated into many parts of our lives. It may feel like life has always been this connected, but we are still on the frontier. Challenges appear as we innovate and allow tech companies to have a growing influence on society. With this expanding role, we need to have a conversation about ethics and responsibility. Now that healthcare and technology are working together more than ever, that conversation is more important than ever.
Technology has allowed us to make advancements in many areas; safer transportation, better communication, and enhanced productivity and efficiency. There are trade-offs, though. Tech companies collect our data and data about us, ostensibly to improve their products and our experiences. This data can also be used to draw observations and learn about behaviors, make meaningful correlations; to extract realizations you could not otherwise see.
Sometimes we are manipulated. It may be for good purposes to help us quit smoking or make healthy eating choices, or for bad purposes such as predatory lending and phishing scams. Facebook even tested to see if they could manipulate their users' emotions; they were successful. Some of the manipulation is legal, some of it illegal, and we are still determining some effects as new techniques are employed every day. We continue to learn and debate what is right and wrong.
Now that technology is established in almost all clinical settings, the opportunity for manipulation has also been introduced. Unfortunately, harmful actions aren’t immediately apparent because they can be disguised in helpful tools or they can come in the form of well-intended features with poorly understood results.
Case in point: Practice Fusion, a cloud-based EHR vendor, received a fine of 145 million after being found to have influenced physicians through their EHR system to sell more opioid medications. The company solicited a $1 million kickback from Perdue Pharma to let them influence clinical decision support (CDS) alerts in their system. They had input about the messaging and timing when the alert pops up in response to a patient having pain. The investigation found that the triggered CDS alerts didn't always reflect medical standards and appeared 230 million times in a 3 year period. This was intended to sell more opioids as sales declined due to scrutiny of the prescription of opiate painkillers. Additionally, they obtained false EHR certification from the ONC by concealing non-compliance of requirements on several versions of its software.
Practice Fusion was obtained for $100 million by Allscripts, a more established EHR company, in 2018. Allscripts says these practices were going on starting in 2014, well before the acquisition, but they are stuck with the fallout. The acquisition further complicates the accountability in this case.
As a tech company, it is important to look at the consequences of the capabilities you are providing. It is not enough to look at just the apparent results, you have to look at 2nd order and 3rd order consequences - who is impacted and how. In the case of Practice Fusion, the first order is they made an ad sale. If you stop there, it’s ethical - there is nothing wrong with selling ads. But if you go deeper, you begin to see the harm perpetrated. The ads affected how physicians prescribed opioids. The patients received possible health and financial harm in the next order of consequence. Was this a case of short-sightedness or were they aware of the harm being done? The efforts to hide from ONC seem to point to the latter.
We must continue to ask the questions: What are the benefits? What are the costs? Who might be harmed?