Trust by whom, in whom, and in what context?
It’s fairly common to see trust mentioned as needed, desired, or required to achieve a given outcome. For example, in the case of health information technology adoption, trust is seen as an essential element for widespread adoption of health IT to succeed. Looking at health IT also provides a good illustration of how important it is to be specific when we talk about trust — it’s not sufficient to say “there has to be trust,” without identifying who or what is to be trusted, by whom, and in what context. Many scholarly conceptualizations of trust define it as a three-part entity, comprising a trustor, a trustee, and a relationship between the two that specifies the scope covered by the trust in question. The attributes of a trusting relationship are important not just to provide clarity, but also to help determine the appropriate basis of trust (that is, what is needed to engender the trust being sought) given the parties to the relationship and the relationship itself.
In the health IT environment, there is not a single discussion of trust, but instead the need for trust is reiterated at multiple levels. Distinct yet overlapping trust relationships that exist (or more specifically, need to exist) were highlighted in May at a panel discussion on e-health at a CIO Symposium held at MIT’s Sloan School of Management. That discussion pointed to trust by individuals (patients) in their doctors or other healthcare providers that their personal health information is being protected appropriately, and trust among providers involved in exchanging health information that patient data is being used for legitimate, authorized purposes. There is yet another type of trust involved for providers seeking to use health information in support of clinical care or medical decision making, which is trust that the data is accurate and its integrity is intact, so that it is actually useful as an input to decision making.
Part of the challenge in establishing the trust that everyone seems to agree is needed for health IT adoption is that the interests of the parties involved are not always aligned, and in some cases those interests may be directly in conflict. With health IT, a further complication arises from the fact that the actions and provisions that may do the most to engender trust among individuals in health IT (such as use of electronic health records and data sharing through participation in health information exchange) also happen to constrain the achievement of the intended objectives and policy outcomes sought through health IT initiatives. Perhaps the group most clearly pulled in multiple directions at once are the providers, who have a critical business interest (and professional obligation) in maintaining strong relationships with their patients, but who are also directly impacted by some of the intended results of health IT adoption, including improving quality of care, reducing costs, and supporting public health promotion and consumer safety. Any efforts made by the government or industry to encourage adoption of health IT has to consider the health care system as a whole and seek ways to make the system overall more trustworthy, otherwise different stakeholders will be hard pressed to reconcile the often competing interests that define their roles.