Ethical Issues and the Patient Portal Essay

Discuss the pros and cons associated with establishing a patient portal system for a healthcare organization in terms of the seven ethical principles identified in your textbook. Identify the problems related to maintaining patient confidentiality and the processes a nurse informaticist should utilize to maximize the integrity of such a system. The scoring guidelines for this assignment are provided below. This entire assignment is worth 100 points:
1. This is an individual assignment consisting of a paper limited to 10 total pages, including a title page and reference pages.
2. Provide an introduction for your paper.
3. Discuss the pros and cons of a patient portal system.
4. Provide a literature review of issues related to maintaining patient confidentiality.
5. Discuss the processes the nurse informaticist should use to maximize the integrity of this system.
6. Provide a conclusion for your paper.
7. At least ten references should be identified in the presentation.
8. Use proper grammar/spelling/and APA format guidelines as applicable. Include an introduction and Conclusions or Recommendations section for your paper.  Ethical Issues and the Patient Portal Essay

Ethical Issues and the Patient Portal


The increasing implementation of electronic medical records (EMRs) in healthcare organizations enables patients to freely access their clinical information and take part in their care through the EMR (Dendere et al., 2019). Patient portals are used by healthcare organizations to enable patients to access their EMR information. A patient portal refers to a secure online website that enables patients to handily access the health information if there is internet connection. Patient portals facilitate access to health information like laboratory findings, medication lists, allergies, immunizations, and discharge data. Patient portals also enable patients to connect and communicate with their healthcare providers using secure messaging and make appointments and request prescription refills (Dendere et al., 2019). However, the use of patient portals is sometimes associated with some ethical concerns. Therefore, this assignment will discuss the pros and cons of portal systems, issues related to maintaining patient confidentiality, and the nurse informaticist process.

Pros and Cons of Portal Systems

Patient portal systems improve efficiency in healthcare organizations by easing the communication between healthcare providers and patients. Portal systems save time because patients can fill their information online, receive laboratory findings, and communicate with physicians any time using the patient portal (Dendere et al., 2019). This is time-saving for nurses and receptionists because the messages appear in real-time. Patients are also sent automatic reminders about upcoming appointments decreasing no-shows and this allows physicians to handle a higher number of patients daily. The patient portal also streamlines workflow in healthcare organizations and promotes telehealth by reducing unnecessary patient visits to hospitals, allows remote monitoring of patients, and saving healthcare costs (Grossman et al., 2018). Moreover, because the portal system is automatic, the software can automatically check for any medication allergies or interactions thus reducing medication errors. More importantly, patient portals improve the sharing of information among healthcare providers, which improves care coordination, reduces duplicate tests, promotes personalized care, and thus improves the quality of care and patient outcomes. The portals also engage patients as active participants during their care, further improving the quality of care (Grossman et al., 2018).

However, patient portals are associated with various pitfalls. For example, navigation of the portals can be difficult, and thus patients may struggle to comprehend their medical/health information. For instance, a study by Miller et al (2016) established that patients found portals not user friendly and some did not understand their findings displays and graphing. Portals also pose a threat to practice because they can hinder workflows and increase stress for healthcare providers (Miller et al., 2016). For example, sometimes patients may send many inappropriate messages to nurses and physicians, which may be overwhelming for the clinical staff. More importantly, patient portals pose a threat to the privacy, confidentiality, or security of the patient’s health information. The patient portals have privacy-sensitive information and thus the increased access to this information by patients poses a risk that someone else may gain unauthorized access to the portal and thus access the patient’s health information, breaching patients’ security, privacy, and confidentiality (Kooij et al., 2018).  Ethical Issues and the Patient Portal Essay

Literature Review on Maintaining Patient Confidentiality

The ethical principles of patient beneficence, nonmaleficence, and autonomy provide a strong basis for developing patient portals. However, However, the digital environment for the patient portals challenges these ethical concepts by changing the nature of access to the patient information.  According to MS et al (2018) despite the convenience and fast access to patient information through portal systems, there is a need to limit access to protect the privacy of the patient and to maintain a trustful relationship between the patients and healthcare providers. This, therefore, means that the confidentiality of health information in the patient portals should be actively maintained. This is supported by Balestra (2017) who explains that the shared information due to the clinical relationship is deemed confidential and thus should be protected. The risk of a breach of confidentiality of health information is high with electronic medical information such as information accessible through the patient portal. Therefore, McDermott et al (2016) explain that nurses should be vigilant to prevent any unsanctioned access to patient information, such as the internal threat from poor management of passwords, accessible physical security measures, disloyal colleagues, and theft of electronic equipment with health information.

Noroozi et al (2018) provide that the key to maintaining the confidentiality of patient information is ensuring that only authorized parties can access the information. For example, the practice administrator determines the relevant users, the level of needed information, and then allocated the username and a password. The passwords should be changed regularly and password reuse prohibited to prevent unauthorized access to the patient information. McDermott et al (2016) also add that confidentiality of patient information should be maintained through access control and audit trails. While access control controls and limits those who access patient health, audit trails document the user information like the person, time, date, and situation when the information was accessed. Audit trail aims to sense any security breach, reconstruct security events, and prevent future reoccurrences.


Moreover, intentional breach of information security can occur when healthcare providers violate the security guidelines. This is because healthcare providers have access to patient information depending on their role and thus breaching the security guidelines can compromise the confidentiality of patient information.  Therefore, Balestra (2017) suggests that the staff should strictly adhere to implemented policies and uphold their ethical values to maintain the confidentiality of the patients’ health information.

Moreover, the Health Insurance Portability and Accountability Act (HIPAA) provides the security and data privacy provisions to protect the health information of the patients. As per the HIPAA security and privacy rules, employers responsible for the actions of their staff. The breach or failure to implement privacy measures when using the patient portal system can result in a violation of HIPAA rules (Abouelmehdi et al., 2018). Controlling access to the patient information is thus inadequate for safeguarding the confidentiality of health information. Organizations are required to add more security measures like training employees about the security of information and implementing security and privacy policies to secure patient information.

The Processes to Maximize the Integrity of the System

Data integrity means that the information is supposed to be accurate, complete, up-to-date, and consistent. Therefore, it is important to ensure the integrity of the patient portals because the data in the system is used in making clinical decisions for the patient.

The nurse informaticist has the role of ensuring integrity, confidentiality, and availability of the protected patient information in the patient portals. The health information should be reasonably protected from the expected risks or hazards to the integrity or security (Abouelmehdi et al., 2018).

The nurse informaticist should ensure that the patient portals are adequately protected using usernames and passwords and only authorized individuals have the passwords (Bowman, 2015). The password used to log into the patient portals should be changed automatically after approximately 90 days to ensure added security. Only individuals required to assess the health information should be granted access.

The nurse informaticist should facilitate disabling automated insertion (copying and pasting) previous results or outdated health information when the information is not changed to be patient-specific and relevant to the incident as this can affect the integrity of the data (Vimalachandran et al., 2016). Moreover, this should be integrated into the system’s standard operational procedure (SOP) as well as the organizational policy. The data should also be protected from external attacks through firewalls or by encrypting any data containing patient health information.

The nurse informaticist should also design and support the implementation of procedures and policies that prevent fraud due to the intentional falsification of patient information. The policies and procedures should require the healthcare providers to provide care and conduct business ethically and implement and use procedures, policies, and system functions and capabilities aimed to prevent fraud (Vimalachandran et al., 2016). Moreover, the systems with capabilities and functions to prevent unauthorized access to the patient information or any fraudulent activity should be integrated into the patient portal system (Bowman, 2015). The nurse informaticist should also make sure that the end product in the portal system adheres to all the regulatory, coding, documentation, billing, and payer guidelines.  Ethical Issues and the Patient Portal Essay

Audit integrity is also important in ensuring the integrity of the portal systems. The audits ensure that the health record documentation in the patient portal systems supports the scope of the reported services, and only the authorized users can access or make entries to the patient information. The audit trails should encompass the user name, the application prompting the audit, the specific document, description of the audit event, the work station, as well as the time and the date of the audit (Vimalachandran et al., 2016). The audit trail should capture the amendment in the patient’s health information and present auditors with the beginning point for adherence audits. A patient portal without adequate audit trail functionality may generate uncertainty in the integrity of the patient’s health information.


Patient portals provide secure access to health information like laboratory findings, medication lists, allergies, immunizations, and discharge data and communications between patients and their healthcare providers. Patient portals are associated with increased efficiency, convenience, reduced errors, remote monitoring of patients, and thus improved quality of care. However, the patient portals may not be user friendly to some patients they also pose a threat to practice because they can hinder workflows and increase stress for the healthcare providers. Moreover, the availability of the patient information in the patient portals makes the information susceptible to unauthorized access. This may affect the confidentiality and privacy of the patient’s information. Finally, the nurse informaticist has the role of ensuring integrity, confidentiality, and availability of the protected patient information in the patient portals.


Abouelmehdi, K., Beni-Hessane, A., & Khaloufi, H. (2018). Big healthcare data: preserving security and privacy. Journal of Big Data, 5(1), 1.

Balestra, M. L. (2017). Electronic health records: Patient care and ethical and legal implications for nurse practitioners. The Journal for Nurse Practitioners, 13(2), 105-111.

Bowman S. (2015). Impact of electronic health record systems on information integrity: quality and safety implications. Perspectives in health information management, 10(Fall), 1c.

Dendere, R., Slade, C., Burton-Jones, A., Sullivan, C., Staib, A., & Janda, M. (2019). Patient Portals Facilitating Engagement with Inpatient Electronic Medical Records: A Systematic Review. Journal of medical Internet research, 21(4), e12779.

Grossman, L. V., Masterson Creber, R. M., Ryan, B., Restaino, S., Alarcon, I., Polubriaginof, F., Bakken, S., & Vawdrey, D. K. (2018). Providers’ Perspectives on Sharing Health Information through Acute Care Patient Portals. AMIA … Annual Symposium proceedings. AMIA Symposium, 2018, 1273–1281.

Kooij, L., Groen, W. G., & van Harten, W. H. (2018). Barriers and Facilitators Affecting Patient Portal Implementation from an Organizational Perspective: Qualitative Study. Journal of medical Internet research, 20(5), e183.

Miller, D. P., Jr, Latulipe, C., Melius, K. A., Quandt, S. A., & Arcury, T. A. (2016). Primary Care Providers’ Views of Patient Portals: Interview Study of Perceived Benefits and Consequences. Journal of medical Internet research, 18(1), e8.

McDermott, A. M., Pedersen, A. R., Anthony, D. L., & Stablein, T. (2016). Privacy in practice: professional discourse about information control in health care. Journal of Health Organization and Management.

MS, A., GF, H., SHE, L., & ANSJ, J. (2018). EMR Access and Confidentiality Based on Patient and Hospital Staff Perspectives. The Open Public Health Journal, 11(1).

Noroozi, M., Zahedi, L., Bathaei, F. S., & Salari, P. (2018). Challenges of Confidentiality in Clinical Settings: Compilation of an Ethical Guideline. Iranian journal of public health, 47(6), 875–883.

Vimalachandran, P., Wang, H., Zhang, Y., Heyward, B., & Whittaker, F. (2016, December). Ensuring data integrity in electronic health records: a quality health care implication. In 2016 International Conference on Orange Technologies (ICOT) (pp. 20-27). IEEE.  Ethical Issues and the Patient Portal Essay

Here are the basic seven guiding principles and a quick explanation of each.

  1. Beneficence. This comes from the same word as benefit, which means to do good for others or to remove them from harm. It is actually, in my opinion the overarching principle that guides nursing practice.


    2. Nonmaleficence. This word comes from the same word as malice, which means to hurt someone else, so non-maleficence then means to not hurt others. It is often confused with Beneficence but the two are completely different. Nursing practice is based on the principle of beneficence, our laws are based on the principle of nonmaleficence. For example as a nurse our profession asks us to help patients, but the law tells us not to hurt them. (Keeping this simple).
    As another example the law would note that we can not hit a pedestrian while driving our car – that is nonmaleficence, but we are not required by law to help them across the street – that is beneficence.

    3. Fidelity. We are probably more familiar with the term infidelity, which means to not keep one’s commitments. Fidelity is then keeping one’s promises and commitments. We have fidelity to our patients and actually to our employer, and at times these can be at odds with each other and cause us many problems.

    4. Veracity. This word comes from the same word as verify, it literally means the whole truth and nothing but the truth, to really look closely at what is going on and to tell the truth about it. I always think it is interesting to think of a court of law where some matters of truth may simply not be admissable, there are good reasons for this, but then, really speaking it is not ‘telling the whole truth and nothing but the truth…..;’

    5. Paternalism. This word comes from the same word as father, we are all familiar with the term paternal. But this specifically means being like a father in making decisions for others. It is one of the most fascinating of these principles because we typically think of this as a bad thing, we place a very high value on patient autonomy, and want patients to make their own choices. So as a sidebar I have had this conversation numerous times with nurses. The complaint is that patients are non-compliant. And so then the nurse wants to do what? Educate the patient more. But if the patient does know and has made their choice, then that education may be seen as manipulative, not letting them have their own say so. Right? Paternalism is seen as good in times where we have those who do not have the ability to make their own decisions, infants, those with dementia come to mind.

    6. Autonomy. Literally means self-governance, or making decisions’ for one’s own self. I will come back to this one in a moment because of all of these I think it is the least understood…and honestly maybe the most complicated!

    7. Justice – which we take to mean giving one what is due to them. In front of most court houses in the USA we see a women who is blindfolded holding a set of scales. This is a great way to think of justice. The issue of being blind is to avoid consideration of bias, and the scales mean that the court seeks to balance the scales when a wrong has been done to someone one. So for example even if by accident I throw or hit a ball that breaks my neighbor’s window, if need be the court will step in and assess how I have damaged my neighbor’s property and they will work to balance the scale, so the neighbor might get a bid for how much it will cost to replace the window and the remedy would be I would be required to pay it, and there might be a restraining order on me to not play golf in my backyard :). Or as it is often said the punishment should fit the crime….

    Okay before I go further, let’s talk about autonomy. Autonomy is often thought of as being a yes/no situation. It is not. Instead think of autonomy as being on a continuum from say 0% or absolutely no autonomy to 100% having full autonomy. I would suggest that (in theory) we seldom are in a position where we are at 0% or even 100%, if we truly think about what autonomy really means, but rather usually we are say operating in the 25-75% range. Okay then autonomy is actually made up of two other concepts, and both of these are also on a continuum. They are knowledge of what our actions and decisions will do and freedom of coercion or duress. So let’s take a simple example. We go into a patient’s room with a surgeon to talk about an operation the patient needs and to obtain informed consent. To maximize knowledge the patient needs to understand the risks and benefits of the surgery in words they understand. This may not be 100% possible, but we can say we do the best we can. In terms of coercion, let’s say the patient’s wife is in the room too and the patient really might want to hear by himself, but he can’t very well ask his wife to leave either, and so her opinions (for better or worse) enter into the decision. The mere fact that his wife is present might actually reduce his freedom of duress, yes his decision might be much better – right? but he might actually, just by the presence of another family member in the room, not be totally free of even a minimal level of coercion. So the bottom line here is when it comes to autonomy think of two concepts, knowledge and freedom of coercion as being on a continuum from 0-100%…and to maximize autonomy we have to maximize both of these. As a sidebar we often hear that nurses want autonomy, in particular an NP, in their practice. I think we understand this, perhaps without saying it, that what we really mean is that for example the NP wants to maximize their autonomy, absolute autonomy may not be ever achievable, by any health care provider. Right?

    Okay back to the ethical principles then. What I realized after teaching ethics for some 12 years or so, was that when we have an ethical dilemma it is because we are struggling between two of these ethical principles that are in opposition to each other, and to me, again my opinion here, it becomes a bit easier to make a decision if we are able to identify the ethical principles that are in conflict with each other. Here are just a few quick examples to help you think in this manner.  Ethical Issues and the Patient Portal Essay

    a. Fidelity vs Fidelity… A nurse manager is having trouble reducing staffing on her unit, without any laws (such as in California) that dictate nurse patient ratios. Her dilemma is due to the conflict of fidelity towards the organization and fidelity towards the nursing staff – and ultimately the patients. This is often viewed as the greatest ethical dilemma nurse managers and leaders face.

    b. Paternalism vs Autonomy… We put such a high value on autonomy that we will allow patients to make choices, even when we know that they are unhealthy choices. So paternalism is often seen as a “bad” thing. There are times when we do value paternalism. For example when a person gets to the point through dementia or Alzheimer’s that we feel it is unsafe for them to make their own decisions, or in the case of children we often make health care decisions for them, and then in cases where we have a suicidal patient whom we have to restrain. Paternalism vs autonomy also plays out with insurance issues, even as we have seen in the past where a group does not want a certain type of coverage but are forced to have it. Or where people (again not stating the value here as being good or bad) are forced to have health insurance whether they want it or not. As a sidebar here I just returned from a national health care policy conference that was great. The main speaker however said we have never come to the decision as a nation as to whether health care is a right or a commodity, she is right, I think, for what it is worth my opinion is that it is both, but as I listed I also thought it is actually now a requirement. Again not speaking to the merits of this or lack of merits, but now we actually have a situation, where we can view health care as a right, a commodity, and/or as a requirement, and again, just looking at this from my perspective it may need to be thought of as being a blend of all of these, and even other issues we have yet to explore.

    c. Veracity vs Nonmaleficence…okay consider this example. Jerry is visiting his friend who has just had a baby. Jerry think the baby is the ugliest baby he has ever seen. But he is torn when she says “Jerry isn’t my baby beautiful?” because he wants to tell her the truth, but doesn’t want to hurt her feelings. And so as he looks at the baby he tells a lie, “Oh yeah, she is something special…” because in quickly weighing out the situation he figures the truth in this case would be a poorer choice than non hurting his friend.

    At any rate, if faced with a dilemma try to identify the ethical principles in place, and this might help you determine which is of higher value given the situation.

    3. Ethical decision making techniques. There are quite a few, but the two I like best are moral traces and the front page test.
    a. Moral traces is sort of like how you feel about a decision. So in an ethical dilemma we make a decision, but before we carry it out we ask ourselves, ‘how do I feel about this?’ or some would say “how do I feel in my gut about this” or even “what does my intution tell me about this decision….”
    b. The front page test goes back to a time when everything was in print. If you are into social media I think now we could call it the “Facebook test” at any rate in this test you imagine that your decision is the front page news, or has gone viral, – how would you feel about that? You can even think of having two or three decisions. Imagine choosing each and then having that decision go viral for the whole world to see. Would you be happy, proud, etc. of that decision? Often times when we think of how we would feel about a decision after the fact it becomes sort of like a hindsight issue in reverse, we can think about things before we do them.

Ethical Issues and the Patient Portal Essay


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