Peer Reviewed Journal on Ethical Issues in Electronic Health Records

Abstruse

Electronic health records (EHRs) provide benefits for patients, physicians, and clinical teams, but besides heighten ethical questions. Navigating how to provide care in the digital age requires an cess of the impact of the EHR on patient intendance and the patient–md relationship. EHRs should facilitate patient care and, as an essential component of that intendance, support the patient–doctor relationship. Billing, regulatory, research, documentation, and authoritative functions determined by the operational requirements of health care systems, payers, and others take resulted in EHRs that are better able to satisfy such external functions than to ensure that patient care needs are met. The profession has a responsibility to identify and address this mismatch. This position paper past the American College of Physicians (ACP) Ideals, Professionalism and Human Rights Committee does not address EHR design, user variability, meaningful use, or coding requirements and other government and payer mandates per se; these bug are discussed in particular in ACP's Clinical Documentation policy. This newspaper focuses on EHRs and the patient–physician relationship and patient intendance; patient autonomy, privacy and confidentiality; and professionalism, clinical reasoning and training. It explores emerging ethical challenges and concerns for and raised by physicians beyond the professional lifespan, whose ongoing input is crucial to the evolution and use of information technology that truly serves patients.

INTRODUCTION

Confusing innovations are a double-edged sword, bringing both opportunity and risk. The electronic health record (EHR), for example, simultaneously facilitates and complicates the commitment of health care.

When Laennec introduced the stethoscope in 1816, disrupting "the tradition of direct (skin-to-skin) contact" in listening to the patient's center and lungs, it had consequences.1 Many physicians thought the innovation would be a detriment to care. This led to a reexamination of ways to sustain the patient–physician relationship, and the subsequent integration of the engineering science with other forms of therapeutic touch on, conversation, and communication.

Today, technologies that aid the delivery of care are ubiquitous. EHRs have demonstrated value in features such as legible information, authentic prescriptions, remote access to data, and prevention reminders. Many patients use portals to cheque data and communicate with physicians.ii But EHRs also bring unintended consequences.3

"The primary goal of EHR-generated documentation should be curtailed, history-rich notes," and technology should support care goals "in the most efficient mode possible without losing the humanistic elements of the record that support ongoing relationships…."four Computers are tools. They practise not fundamentally modify the goals of medicine or the ethical responsibilities of the profession.

EHR evolution, however, has focused not on capturing the patient's story and physician'south thought processes and intendance plans, but on billing, authoritative, and regulatory elements.four,v, ^– 6 Documentation requirements take led to check-box and drop-down menu shortcuts; repetitive and sometimes inaccurate information is perpetuated.7 While some functions can enhance the speed and structure of documentation, unreasonable requirements tin impose their own burdens.

Although policy bodies accept recognized the potential for health information technology (HIT) to improve intendance, they have likewise cautioned that HIT does not effectively support the diagnostic process and may contribute to errors.8 For example, "challenges include problems with usability, poor integration into clinical workflow, difficulty sharing a patient'south health information, and a express ability to support clinical reasoning and identification of diagnostic errors in clinical do."viii These challenges give ascent to upstanding concerns that are not only the problem of HIT professionals, and must be addressed by the medical profession. "The adoption of EHRs causes significant changes in the day-to-day experience of those practicing medicine… To realize the promise of EHRs, more piece of work is needed."9

Moving forward, we would do well to think the words of T.Due south. Eliot: "Where is the wisdom we have lost in knowledge? Where is the knowledge we take lost in information?"10

POSITION 1: EHRS AND COMPUTER Employ SHOULD FACILITATE PATIENT CARE, Back up PHYSICIAN Ethical DUTIES, AND Support THE PATIENT–PHYSICIAN Human relationship

Patient–Physician Relationships

It seems obvious that patient care should center on interaction with the patient. The design and utilize of EHRs tin can facilitate patient education during a visit, only EHRs can as well be an even greater distraction than the paper tape, diverting the physician'due south attention away from the patient.11 Physicians must put the welfare and best interests of the patient first, and effective communication is critical to care.12 Some take called the figurer the "third party"13 in the exam room, with its introduction into the relationship9 ^, fourteen ^, fifteen having the power to raise or impede advice and relationship-building. In the infirmary setting, reliance on computers is increasing16— leading to a focus on the "iPatient."eleven

All encounters crave sufficient time and attention for open discussion of patient concerns.12 Inadequate listening and human relationship-building can lead to adverse outcomes. Physicians focused on difficult-to-use data requirements tin can miss psychosocial and emotional cues "essential for contextual understanding, differential diagnosis, management, and ultimately, for compassionate, patient-centered care."xiii

Distractions and fourth dimension pressures are not new, but applied science may cause them to be more pronounced. Heavy use of computers by clinicians in safety-net clinics was associated with communication barriers and less satisfied patients.17 Active listening and discussion, eye contact, and thorough concrete exam assistance build therapeutic alliances. Patients feel better cared for and more than confident in patient–dr. partnerships in intendance. The physical exam—and the power of touch—"changes the dynamic" of the meet, ofttimes empowering patients to speak freely.xviii Yet in the ambulatory setting, for every hour physicians provide straight care, nearly 2 hours is spent on EHRs and administrative work.nineteen

Computers allow the patient and physician to view the screen together.14 Strategies for positioning the computer screen and maintaining heart contact can help, along with patient-centered approaches,20 tools for improving non-exact communication,21 and Frankel'southward mnemonic all-time practices device, "POISED" (prepare, orient, information gathering, share, educate, debrief).i These strategies tin can maximize listening, impact, talk, and time. Medicine is a moral enterprise22 "still practiced 1 conversation at a fourth dimension."i

Technology should add value to the patient'south experience.23 Patients, clinicians, insurers, institutions, vendors, and the government must all back up the intimacy and importance of the patient–medico relationship.12

The Ethical Significance of Time

Growing documentation requirements add time pressures on direct patient intendance. The complexity of routine primary intendance visits today—and the tasks to be achieved—has increased, only visit fourth dimension has non.24 Managing today'due south volume of electronic information in primary care with yesterday's staffing ratios is challenging.23

The trouble of inadequate time with patients did non brainstorm with EHRs, only they accept exacerbated it. Typical visits lasting 15–20 min24 followed by completion of documentation have get 15-min visits during which documentation is expected. Some clinicians still document post-visit to reserve the limited fourth dimension for interaction, but this is counter to organizational expectations. Nonetheless, meeting the goals of the see requires adequate time for human relationship and trust-building, active listening and empathy by the physician, and patient advocacy—these upstanding obligations should guide not but physicians but wellness systems also in addressing the importance of providing adequate time, "a necessary precondition for promoting patient well-being, embodied in the ethical principle of beneficence."25

To maximize time, some practices utilize medical scribes who enter information during the visit, allowing the physician to focus on interacting with the patient. One study in an ambulatory urology practise found increased patient and physician satisfaction with scribe use.26 Notwithstanding, concerns have also been reported, including the introduction of another private into the patient–physician encounter, patient hesitancy to fully disclose sensitive information, and the completion of guild entry by scribes. In addition, scribes are unlicensed, required merely to have a high schoolhouse diploma, and may have no wellness care background, highlighting the lack of oversight of the growing medical scribe "industry."27

Some caution that the scribe industry "should be viewed equally what it is: a workaround or adaptation to the suboptimal state of today's EHRs."27 Others see promise in models such equally the nurse "co-visit," a squad approach where nurses provide initial directly patient care, then help with documentation.28 ^, 29

Time pressures in the practice environs also affect how physicians view their professional responsibilities. A RAND study noted frustration among nearly physicians regarding the negative effects of EHRs on loftier-quality intendance, citing poor usability, time-consuming data entry, interference with contiguous interaction, and inefficiencies.30 Some linked the pressure for increased clinical productivity forth with increased documentation requirements as a cistron in clinician exhaustion. A clinically focused patient-centered EHR with reduced administrative requirements could facilitate care and assist minimize burnout. Addressing this issue is imperative, as the care of patients likewise requires attention to the care of clinicians.31 Physicians may feel that their professional integrity is challenged when they cannot provide the care they were trained to provide.

POSITION 2: EHR Utilize SHOULD ASSIST AND Raise CLINICAL REASONING AND THE Development OF COGNITIVE AND DIAGNOSTIC SKILLS. FEATURES SUCH AS Copy-AND-PASTE SHOULD Be EMPLOYED JUDICIOUSLY, REFLECT Idea PROCESSES Nigh THE Current PATIENT ENCOUNTER, AND MEET THE Upstanding REQUIREMENTS FOR AN Accurate AND Complete MEDICAL Tape

Bedside and Diagnostic Skills in Education and Practise

Does computer apply alter how clinicians think and teach? How trainees learn clinical reasoning? Verghese'south "iPatient" is treated based on test results, reports, and EHR data.11 Indeed, first inpatient encounters are often electronic, leading to the "flipped patient" phenomenon.16 In this world, history-taking as a rich dialogue can be lost. Simple, validated, constructive high-value care may be overlooked. "Features in EHRs may encourage learners to make medical decisions or deliver medical intendance without having to interact directly with patients… Without proper preparation and guidance, EHRs can undermine the pupil's development of patient-centered care practices."32 Reports take noted a decreased ability among learners to synthesize clinical information and the need for EHR skill development.33

Verghese describes a bedside arroyo to establishing a connection to a patient equally a reading exercise: "the torso is the text, a text that is changing and must be frequently inspected, palpated, percussed and auscultated."eleven Charon writes well-nigh the importance of narrative medicine.34 These aspects of interaction provide psychosocial, cultural, and emotional clues to understanding the patient's symptoms, health, and goals,35 which are critical not only to data-gathering, just advice and relationship-building.12 Caring for and learning from a patient—and non primarily an electronic representation of the patient—is essential to the "joy, excitement, intellectual pleasure, pride, thwarting, and lessons in humility that trainees might experience…"11 and in respecting the dignity and uniqueness of each patient.12

Clinical Reasoning

EHRs employ "smart phrases," templates, and drop-down menus to facilitate documentation. Cerebral science research is outset to explore the touch on of "discrete field thinking" on patient care. When a drop-down bill of fare contains five options, none of which quite fit, will the user pass up the structured note selection and type gratis text, or pick a close second to maximize productivity?

Some features of electronic documentation may encourage superficial clinical thinking and interaction.36 Physicians and students may focus on "screen-driven" information-gathering, "scrolling and asking questions every bit they appear on the computer," but not assessing the patient's current needs.13 Diagnosis-specific prompts may "inadvertently narrow the telescopic of inquiry prematurely, a common cause of diagnostic fault,"xiii and impede the evolution of skills and reasoning.37 The patient'southward narrative and clinician's reasoning should not be lost to pre-populated phrases and driblet-down menus.

On the other hand, guided documentation, as that for necessary preventive and chronic care services, can be valuable. Clinical decision back up (CDS) tools, prompts, reminders, and medication and allergy alerts can exist a helpful use of structured data.4 However, there can exist problems in implementation. Templates and check-boxes may not always be relevant to current care, but crave a box to exist checked to close a note, calling into question the physician's honesty. Honesty is an ethical responsibility.12 EHRs should always provide a "not asked" selection. Clinically unhelpful tools may outcome in "alert fatigue" and false documentation or upward-coding, whether inadvertent or not. Billing for services non provided is unethical.12

Documentation: Re-create-and-Paste and Note Bloat

EHRs encourage "copy-and-paste" (C&P)—copying previous entries into the current note.38 ^, 39 This might salvage time, but may not reflect current thought processes, leading to unhelpful, repetitive entries. When opportunities for trainees to learn and practice are lost, critical cognitive skill development may be harmed.23 Focusing on features in the patient's initial presentation early in the diagnostic process can lead to the cognitive bias of "anchoring,"40 where the initial impression is not adjusted, even given new information. Although too a chance with paper documentation, smart phrases and templates may prompt a narrowing of the diagnostic horizon.

C&P without attribution may perpetuate inaccuracies and even constitute fraud. Fixed aspects of a notation should exist designated—for case, "the initial visit documents Mr. Sanchez underwent an appendectomy at age 58." At the adjacent visit, the physician could review accuracy, notation that the medical history was updated with the patient, and note/date stable elements incorporated from the prior note. The risks of C&P can outweigh its benefits; it should exist used judiciously. Guidelines for best practices are needed.

EHRs also suffer from "annotation bloat," or lengthy extraneous information from previous entries. C&P exacerbates note bloat every bit does template-driven importation of information (onetime laboratory or other results), burying relevant information.39 Whereas illegible paper records contained disorganized notes, EHRs tin capture big amounts of repetitive information. Accurate consummate data in the medical record—paper or electronic—is an ethical responsibility.12

POSITION 3: PRIVACY AND CONFIDENTIALITY MUST BE MAINTAINED IN EHR Utilise. EHR INFORMATION RETRIEVAL, EXCHANGE, AND REMOTE Access CAN Meliorate Intendance, BUT ALSO CREATE THE Run a risk OF UNAUTHORIZED DISCLOSURE AND Utilize OF PROTECTED HEALTH Data

Patient Privacy/Confidentiality

Instant retrieval and data substitution through EHRs improve intendance, merely as well create the risk of unauthorized use, access, and disclosure of private patient information, raising confidentiality and privacy concerns. Unauthorized access could also have implications for patient family members if genetic information is involved.

Respect for patient autonomy requires that patient encounters and information are kept confidential and private, fostering trust and improving communication.12 Otherwise, patients might not disclose important information or may avoid seeking care, fearing denial of insurance, loss of employment, or stigmatization. While this is also true of paper records, concerns are heightened with EHRs because information is so readily transmitted and system breaches are not uncommon, despite security measures. Breaches may occur accidentally, through cyber attacks, or due to lapses in professional deport, such every bit searching for test results of a family fellow member or celebrity. All of this is easier to accomplish—and rails—electronically.

Access to Information

As a thing of police and ideals, patients have a right to the information in their medical records.12 EHRs can increment participation and date in health intendance through patient admission,41 empowerment, and improved advice.42 All the same, patients may not be aware that they can access their records.43 ACP supports direct patient access to test results merely cautions that patients should hash out results with their physicians.44

"OpenNotes" is an initiative designed to requite patients directly access to their full records, which ACP supports. OpenNotes may exist a powerful tool for improving patient health and engagement4 ^, 42 and the accuracy of information. Opportunities for transparency and patient educational activity through applied science are welcome developments.

Patients and physicians study positive experiences using OpenNotes.42 The noesis that a patient may read a annotation may improve documentation. But total access can also claiming the physician's ability to write candid notes, particularly regarding sensitive information (eastward.g., nigh mental health, substance corruption, sexual behavior, or advent). Would a physician obscure information or a diagnosis, knowing that the patient could admission the note? Construct notes with patient satisfaction surveys in mind? More consideration of these issues is needed.

The Digital Dissever

Patient access to electronic information presents opportunities to meld the "digital culture" with personal responsibility for health.41 Ironically, patients who might benefit almost from digital access may be least likely to accept it. Thus EHRs may exacerbate the "digital divide" between those with and without Internet admission, contributing to health disparities.41 Patients lacking Internet access are more probable to have lower socioeconomic status, educational levels, and wellness literacy and to be elderly—factors associated with poorer health outcomes.45

CONCLUSION

Innovations in health intendance must be consistent with the ethical responsibleness of putting the patient showtime. Ultimately, "the systems we design and the engineering science we use should help enhance the value of what we do."46

EHRs impact patient care, patient–physician interactions, clinical reasoning, and training. Some commentators have gone then far as to say that "encounters have been restructured around the demands of the EHR."47 Now is the time to evaluate how, going forward, EHRs can better come across patient care needs and the responsibilities of medicine.

EHRs are tools that should facilitate high-value patient-centered care, strong patient–physician relationships, and constructive training of future physicians. Anything less… does not compute.

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Acknowledgements

The authors and the American College of Physicians Ethics, Professionalism and Homo Rights Committee would like to thank Jessica Mozersky, PhD, for initial research assistance; Kathy Wynkoop for editorial help; and peer reviewers William B. Applegate, Md, MPH; Rita A. Charon, Dr., PhD; Religion T. Fitzgerald, MD; K. Patrick Ober, Dr.; Jorge J. Scheirer, Md, MBI; Christine A. Sinsky, MD; and the ACP Medical Informatics Committee for helpful comments on drafts, as well every bit JGIM reviewers.

This newspaper, written by Lois Snyder Sulmasy, JD, Ana María López, Medico, MPH, and Carrie A. Horwitch, Doc, MPH, was developed for the American Higher of Physicians Ethics, Professionalism and Homo Rights Committee. Members of the 2015–2016 ACP Ideals, Professionalism and Human Rights Committee at the time the paper was approved by the Committee were: Ana María López, Dr., MPH (Chair); Banu Due east. Symington, MD, (Vice Chair); Omar T. Atiq, MD; John R. Ball, MD, JD; Thomas K. Grand. Cudjoe, MD, MPH; Carrie A. Horwitch, Md, MPH; Daniel B. Kimball, Jr., MD; Lisa S. Lehmann, MD, PhD; Sean R. Lena; Tanveer P. Mir, MD; Paul Southward. Mueller, Doc; Danny Allen Newman, Doctor; Wayne J. Riley, Md, MPH, MBA; and Julie R. Rosenbaum, MD. Approved past the ACP Board of Regents on 9 June 2016.

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Affiliations

1. American College of Physicians, 190 North Independence Mall West, Philadelphia, PA, 19106, The states

   Lois Snyder Sulmasy JD

2. Health Equity and Inclusion, UUHS, Table salt Lake City, UT, Usa

   Ana María López MD, MPH, FACP

3. Collaboration/Appointment Team, Heart for Clinical and Translational Science, Academy of Utah Health Sciences, Common salt Lake City, UT, USA

   Ana María López MD, MPH, FACP

4. Huntsman Cancer Constitute, Salt Lake City, UT, USA

   Ana María López Doc, MPH, FACP

5. University of Utah School of Medicine, Table salt Lake Metropolis, UT, USA

   Ana María López Md, MPH, FACP

6. Virginia Mason Medical Center, University of Washington, Seattle, WA, USA

   Carrie A. Horwitch MD, MPH, FACP

Consortia

, American College of Physicians Ethics, Professionalism and Man Rights Committee

Corresponding author

Correspondence to Lois Snyder Sulmasy JD.

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Sulmasy, L.S., López, A.M., Horwitch, C.A. et al. Upstanding Implications of the Electronic Health Record: In the Service of the Patient. J GEN INTERN MED 32, 935–939 (2017). https://doi.org/10.1007/s11606-017-4030-1

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• Received: 09 September 2016

• Revised: 02 February 2017

• Accepted: 23 Feb 2017

• Published: 20 March 2017

• Issue Date: August 2017

• DOI : https://doi.org/ten.1007/s11606-017-4030-one

Keywords

• Electronic Health Record
• Clinical Reasoning
• Health Information Engineering
• Physician Relationship
• Direct Patient Care

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