A 62-year-old woman presents with severe [vertigo] that has increased in intensity over the past 10 years. She has been evaluated and treated by a variety of physicians at several institutions. One of the reasons the patient has changed doctors is her sense that her previous doctors did not listen to her. As you begin to take her history and type it into the electronic health record (EHR), she shares with you her fears that she is going to end up in a wheelchair like her mother, and she becomes tearful. You stop typing and realize you have spent most of the appointment staring at the computer monitor. You are running an hour late, and four patients are waiting to see you.
Discussion
The adoption of health information technology into medical practice will likely lead to significant improvements in healthcare. Congress is betting on it. With the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009, the federal government, through Medicare and Medicaid, has incentivized clinicians and hospitals who demonstrate “meaningful use” of EHRs. In addition to improving quality and coordination of care, HITECH was designed to decrease medical errors, protect the privacy and security of personal health information, and generate savings.
However, a wide range of ethical concerns associated with the use of EHRs has been identified, including breach of confidentiality and privacy, overreliance on previously obtained patient historical information, and ambiguities regarding the authorship of notes. Critics are also concerned about the possible use of EHR systems to increase physician or hospital billing (Neurology. 2013;80:1057-1061; J Med Ethics. 2012;38:535-539).
One of the biggest ethical concerns about the EHR is its impact on the clinical interaction. The presence of a computer in the exam room represents a potential intrusion by a third party, resulting in triangulation of the physician–patient relationship (J Am Med. Inform Assoc. 2014;21:e147-e151). Patients may question the professionalism of a physician who appears to be focusing more on the computer than the patient and perceive the interaction to be paternalistic. They may misunderstand what the physician is doing with the computer and wonder whether it is in the patient’s best interest for such a distraction to be present. With the physician’s eyes glued to a computer, the perception of a patient-centered approach may be lost. And, if studies demonstrate that using an EHR compromises the quality of the clinical interaction, financial incentives to use an EHR could introduce a conflict of interest.
Several solutions to this problem have been proposed. One approach is to have a medical transcriber in the exam room, someone who could document the information provided by the patient. Although transcription would free up the physician to focus on the patient, this option is potentially costly and associated with its own ethical concerns. Having a transcriber in the room could be considered a violation of a patient’s privacy. It could also impede the physician–patient relationship by inhibiting patients from raising sensitive or embarrassing issues. Voice-activated recording devices would provide automatic transcription, but capturing every word spoken by the patient might lead to voluminous, difficult-to-read notes. Sharing the computer screen with the patient has the potential to transform the EHR into a tool that supports shared decision making by facilitating physician–patient communication. For this to occur, optimally, the computer must be on a mobile arm so the patient can see it (Ann Fam Med. 2006;4:124-131). Some physicians use a listen-now-type-or-dictate-later approach. This may be the solution associated with the fewest ethical concerns that best maintains the physician–patient relationship, but it comes at a cost, as “typing later” adds time to the physician’s day.
A variety of approaches to improving communication while using EHRs has been suggested, starting with informing the patient what you are doing, avoiding computer use when sensitive psychosocial issues are at hand, and involving patients in building their charts. Practical steps can also help, such as learning to type and pointing at the screen (Fam Pract Manag. 2006;13:45-47).
Somehow, we must learn how to retain the patient’s narrative, both in the elicitation of the history and its documentation through EHR (Acad Med. 2011;86:11-14). And we need to be available to interact with that narrative, or we risk becoming the equivalent of computers ourselves.
Back to the Patient
After pushing the keyboard aside, you explain what you’re typing on the computer and how electronic health records have the potential to improve care. She seems impressed that your computer can check for drug interactions, a point of particular interest to your patient because her medication list is long. After discussing her [dizziness] and available treatment options, she is reassured that “ending up in a wheelchair” is not likely. Your visit is a minute or two longer than you’d aimed for, but your relationship with this patient is back on track.
Elizabeth A. Kitsis, MD, MBE, is director of bioethics education and associate professor of clinical epidemiology and medicine at the Albert Einstein College of Medicine. She is a member of the ACR’s Committee on Ethics and Conflict of Interest.
Robert H. Shmerling, MD, is the clinical chief of rheumatology at Beth Israel Deaconess Medical Center in Boston and the chair of the ACR’s Committee on Ethics and Conflict of Interest.
This article has been adapted with permission from the American College of Rheumatology.