Electronic health records (EHRs) “will thoroughly change our ethical understanding of the doctor-patient relationship, and will probably require us to rethink it within this digital framework,” says Tania Moerenhout, MD, PhD, a general practitioner and former researcher in the departments of public health and primary care and the department of philosophy and moral sciences at Ghent University in Belgium.

Researchers interviewed 14 primary care physicians about EHRs and identified some common themes.1 “Ethical questions that arise with daily use of the EHR within our work remain underexamined. This study tried to fill that gap,” says Moerenhout, the study’s lead author. The physicians interviewed brought up a few issues:

A shared record raises ethical questions on autonomy and trust. Patients interviewed by Moerenhout seemed to appreciate when someone asked for their input on what should be included in the EHR.

“This does not happen often enough in patient-doctor interactions,” Moerenhout shares. One clinician included a patient’s difficult background of rape, prostitution, and homelessness in the EHR. He did it because some would write off the patient as “difficult.” This clinician hoped the information would provide some added insight. “He had clearly given it a lot of thought, but he had not considered talking to her about it,” Moerenhout says.

The physician wanted to help the patient, but there also was the potential for harm. “Both the lack of information, and access to all information, could lead clinicians in the wrong direction — for example, through anchoring bias,” Moerenhout adds.

A shared EHR may cause certain healthcare providers to avoid seeking help for sensitive issues. “We usually do not think of care providers in a help-seeking role,” Moerenhout observes. Some hospitals grant doctors’ records a higher level of protection. “But we should really think about whether it is sufficient, and whether we should pay more attention in general to doctors-as-patients within the digital medical world,” Moerenhout offers.

The EHR can disturb rapport with patients, but also can support patient/doctor interactions. Some physicians strongly believe EHRs are getting in the way of relationships with patients. “The best way for clinicians to tackle these issues is to open up a conversation about [EHRs] with their patients,” Moerenhout says.

The study’s findings are a clear indication that more ethical design of EHRs is needed, according to Moerenhout. “We need to go back to the drawing table with IT people, healthcare providers, ethicists, and patients to reconsider what we want to do with our EHRs,” she says.

The additional workload EHRs create for physicians — specifically, the need to respond to messages delivered via EHR-based inboxes — is another ethical concern. “Physicians are becoming increasingly burned out, which can negatively impact patients,” says Daniel R. Murphy, MD, MBA, who authored a paper on this topic.2 Murphy is an assistant professor and medical director in the department of medicine at Baylor College of Medicine. Researchers later interviewed 2,104 primary care physicians about the problem. Many believed there was insufficient time to respond to all inbox notifications.3 “While our findings largely confirm anecdotal concerns that have been voiced by physicians about EHR inboxes, we were surprised to find the magnitude of the problem,” says Murphy, a health services researcher at the Center for Innovation in Quality, Effectiveness, and Safety at the Michael E. DeBakey VA Medical Center in Houston.

Most respondents (69%) expressed concerns about receiving messages that were not actionable for patient care or relevant to the clinician. “This suggests physicians are getting a large amount of messages that they really do not need, not unlike spam emails,” Murphy says. This takes up time that could be used for patient care. Currently, managing inbox messages is a nonreimbursed service.

“Healthcare organizations and payers need to recognize the importance and prevalence of this non-face-to-face activity on the quality of patient care,” Murphy says.

As it stands now, many physicians end up responding to all their inbox messages on their own time. “Physicians are pushed toward doing these activities after clinic hours — now, commonly called ‘pajama time’ in healthcare — or to rush through it without giving it the attention it needs,” Murphy says.

REFERENCES

  1. Moerenhout T, Fischer GS, Saelaert M, et al. Primary care physicians’ perspectives on the ethical impact of the electronic medical record. J Am Board Fam Med 2020;33:106-117.
  2. Murphy DR, Meyer AN, Russo E, et al. The burden of inbox notifications in commercial electronic health records. JAMA Intern Med 2016;176:559-560.
  3. Murphy DR, Satterly T, Giardina TD, et al. Practicing clinicians’ recommendations to reduce burden from the electronic health record inbox: A mixed-methods study. J Gen Intern Med 2019;34:1825-1832.