Information Technology Reference
In-Depth Information
ETHICAL AND
SOCIETAL ISSUES
Systems analysts and developers carry a significant amount of
responsibility on their shoulders. Information systems play an
important role in the success of today's businesses, and a faulty
system can mean the end of a business or worse. When informa-
tion systems mean life and death to clients, much more is at stake
than a business's reputation.
Such was the case with a major healthcare organization, which
for the sake of anonymity is called HCO in this article. In 2004, HCO
decided it would be more economical to handle all of its kidney
transplants itself rather than using a nearby university medical
center. HCO built a new kidney transplant center to handle their
kidney transplant patients and named a director. The director
began to transfer all the patient records from the university medi-
cal center to the new center—over 1,500 patients in all.
However, rather than coordinating with the university medical
center to transfer patients and their data from one information sys-
tem to the other, HCO decided to forgo the usual systems develop-
ment process and rush the transition.
The staff at the previous medical facility found themselves ill-
equipped to process and transfer the large number of patient
records to the new center in the necessary amount of time. They
discovered that the data in many patient records was incorrect,
and until they corrected it, the center's staff could not process the
patient records. Managing kidney transplants is complex and time
sensitive. Kidneys are in rare supply and those eligible for trans-
plants spend time on a waiting list, hoping they will be called
before their own kidneys give out. Due to the glitch in data transfer,
hundreds of patient records were lost.
To make matters worse, the new transplant center was under-
staffed and underfunded. Because it did not have proper informa-
tion systems, the staff at the new center maintained medical
records primarily on paper. They did not have a system to deter-
mine if any patient records were lost in the transfer, nor could
patients use a system to voice concern or lodge a complaint.
Over two years, patients whose records had failed to transfer
to the new facility were still waiting for the call for a new kidney
that would never come. Finally, based on a whistleblower's story, a
local TV station and newspaper began pressing the new center to
reveal why patients were waiting longer than usual for transplants.
The investigation quickly led to formal litigation against HCO on a
number of counts, not the least of which was HCO's failure to
adhere to five state and 15 federal regulations mostly dealing
with the management of patient records. The state Department of
Managed Health Care (DMHC) has concluded that the problems
experienced by HCO and its patients are due to “lack of effective
planning” and that the absence of proper information manage-
ment posed “potentially life-threatening delays in care.”
In fact, “potential” appears to be “actual” as further investiga-
tion shows that in the first year of operations, twice the typical
number of patient deaths were caused by an extended wait for
kidneys. Professionals in the transplant business say that this is
the worst problem the industry has ever seen.
Eventually HCO abandoned its plans for a new center and
returned all of its kidney patients to their previous care. The organi-
zation has paid $2 million in fines to the state Department of
Managed Health Care (DMHC) and volunteered another $3 million
in contributions to a transplant education group. Meanwhile, over
50 patients and families of people who died waiting for kidneys are
suing the organization in separate cases, mostly for negligence or
wrongful death.
As investigators sort through this case seeking an explanation
of exactly what went wrong, those involved are accepting some
blame, but also pointing fingers at each other. One thing is clear:
Had proper systems development practices been put into place,
the new kidney transplant center would be operational, patients
lives would have been saved, and the reputation of the previously
well-respected HCO would still be sparkling.
Discussion Questions
1.
What went wrong at HCO? Who paid the price?
2.
How is HCO responding to its mistakes, and how might it
further regain its good reputation?
Critical Thinking Questions
1.
What legitimate reasons might HCO's director provide for
the failure of the new center? Is there any acceptable
excuse? Who within HCO is ultimately to blame?
2.
What other life-threatening or life-saving information
systems are at risk of similar catastrophes?
SOURCES: Gage, Deborah, “We Really Did Screw Up,” CIO Insight, May 14,
Kaiser Permanente Web site,
www.kaiserpermanente.org,
accessed July 12,
2008.
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