EHR use growing fast, but ethical concerns are, too

Confidentiality is "inviolate obligation"

Access to the electronic health record (EHR) of an individual patient as well as what the person looking at the record does with that information remain concerns for all professionals and institutions involved in patient care. Confidentiality, in particular, remains "a major ethical concern," according to Stephen T. Miller, MD, MACP, Pearce Professor of Medicine at University of Tennessee and medical director of medical education and research at Methodist LeBonheur Healthcare in Memphis.

Institutions have used aliases and deception to assure that celebrities have privacy and their autonomy is not violated, underscoring ongoing concerns about confidentiality. "Education of all who have access to the EHR, and public reporting of penalties of those who do not follow the rules, have improved the atmosphere in which EHRs are used," says Miller. "There will be an ongoing need for professional education and reminders for all EHR users to keep confidentiality as an inviolate obligation for patient care."

Data stored in electronic format are susceptible to security breaches, such as health care providers who improperly access a patient's record, allow bystanders to gain access to unattended computer stations, or inappropriately provide their access codes to others. "Even access by authorized parties can lead to threats to privacy and confidentiality," says Beverly Kopala, PhD, RN, associate professor at Loyola University Chicago's Marcella Niehoff School of Nursing. "Data sharing is designed to promote quality and continuity of care. But as ease of access to health information and the number of parties with whom data are shared increase, the opportunities for security breaches increase as well." Additional threats arise when data are "lost" during transfer and when de-identified patient datasets become available for secondary use and are able to be re-identified.1

"Meaningful use" attestation, which obtains payments for those facilities that report meeting requirements, is another ethical concern for institutions and information technology administrators. "The accuracy of these reports is an ethical obligation," underscores Miller. Here are other ethical concerns involving EHRs:

Providers might be distracted during patient care encounters.

"The computer screen cannot become more important than the patient," says Miller. "Communications between providers and patients cannot suffer because the focus is on documentation rather than care of the patient. Distractions violate the principle of beneficence that guides patient care encounters," he says.

Providers might be overwhelmed by too much information.

"Avoiding patient harm is the substantive discussion that clinicians should have about clinical documentations that may be wonderful notes for billing when viewed by coders, but are barriers to patient safety," says Miller.

Can patients be harmed because useful information is hidden by all of the "clutter" that can be collected in an EHR? Miller says the answer is yes. "Copying and pasting to make the record look like something has been accomplished is an ethical error," says Miller. "Repetitious incorporation of laboratory and radiology reports into progress notes when they obscure 'What does the clinician think, and what is the clinician doing?' must be elevated to an ethical concern, if it is going to get the attention of professionals."

EHRs incur financial costs related to development, implementation, and maintenance, such as hardware, software, equipment, personnel, privacy protection measures, and record storage and retention requirements.

"These are substantial and ongoing," explains Kopala. "When limited financial resources must be reallocated to meet these needs, tough decisions about priorities are needed."

Data might be inaccurate.

This can result from intentional or unintentional entry of misinformation, loss or destruction of data when data are shared, and the presence of incorrect information and data that are no longer accurate or relevant to a patient's current status. "This places the patient at risk for harm, as provider decision-making can be negatively impacted," says Kopala. Systems might engender poor quality documentation by expecting overwhelmed providers to document time-consuming details that don't improve care.

"There was an old saying with computers — 'garbage in, garbage out.' I would take that to next level and say even more dangerous is 'garbage in, presumed truth out,'" says Ida M. Androwich, PhD, RN, BC, FAAN, professor and director of health systems management at Niehoff School of Nursing. "This can occur when the provider fails to listen to the patient and over-relies on electronic data, to the detriment of care."


  1. Sittig DF, Singh H. Legal, ethical, and financial dilemmas in electronic health record adoption and use. Pediatrics 2011:127;2010-2184.


  • Ida M. Androwich, PhD, RN, BC, FAAN, Professor and Director, Health Systems Management, Niehoff School of Nursing, Loyola University Chicago, IL. Phone: (708) 216-9276. E-mail:
  • Stephen T. Miller, MD, MACP, Pearce Professor of Medicine, University of Tennessee, Medical Director, Medical Education and Research, Methodist LeBonheur Healthcare, Memphis. Phone: (901) 448-5770. E-mail:
  • Beverly Kopala, PhD, RN, Associate Professor, Marcella Niehoff School of Nursing, Loyala University Chicago (IL). Phone: (773) 508-2896. E-mail: