Electronic medical records (EMRs) were pitched as a long-sought concept of computerized universal personal health material that would mitigate issues with access and barriers to care. In reality, when I speak of EMRs, I am referring to what they actually delivered to physicians, billing platforms that marginalize meaningful patient data necessary to inform diagnosis and therapeutic interventions.
If the promise lived up to an inkling of the reality, then the excessive clerical burden imposed on physicians to enter data, that often results in more eyes on the computer screen than the patient would not cause almost 1 in 5 U.S. physicians to plan to reduce their clinical hours in the coming year and nearly 1 in 50 to expect to leave the field entirely in the next 2 years to focus on a different career (see here).
Since the mandated rollout with financial penalties for noncompliance began, EMR companies selling multiple platforms without input from busy practitioners on the front lines have flourished (see here) at the expense of the doctor-patient relationship. Hospital and health systems have optimized and upgraded their reimbursement flows. A whole industry of coding and billing experts was created. Third party payers have added yet another layer between doctor and patient, entities rarely if ever considered.
So, now with “interoperability” being the du jour euphemism for fixing the ails of EMRs, it still appears that no one is asking questions of the real stakeholders here, the doctor and the patient. After all, any doctor could have identified these issues before EMRs were involuntarily thrust upon them.
Which brings me to my main concern of whether or not such forced implementation of EMRs, considered by some as coercive, violated the basic tenets of bioethics (see source here):
Principle of Respect for Autonomy
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We are responsible for what we do and are truly free to make our own choices. In the healthcare space, physicians are to empower these decisions by patients by providing fully informed consent that is absent of coercion.
Patients and physicians were never asked about the use of electronic medical records, how they would be implemented and the ballooning access to protected health information they encourage. Patients were never fully instructed about the risks and benefits of the endless data EMRs collect that often is not used at all to make treatment decisions on their care. Nor were they consulted on the attention it diverts away from their doctor-patient interactions, time spent and the harm that can cause.
Principle of Justice
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Treatment is fair, equal and follows the law.
Penalizing those physicians in mid- or later career who did not grow up on technology or missed the window for it violates respect for many principles (e.g. the right to practice independent of a large institution and making the attempt cost prohibitive, ageism). It is unjust to do so as it directly contributed to early retirement or expeditious departure from medical practice. Often with EMRs a provider cannot go to the next page without answering certain questions that may or may not have anything to do with the patient’s care. It is always the patient’s right to decide what they wish to disclose. In addition, preoccupying their doctor with unnecessary extra steps can slow down a patient’s getting relief from their suffering. This is not fair to individuals seeking or providing care. It worsens physician shortages, given the burdensome nature of EMRs doctors often cannot see as many patients.
Principle of Beneficence
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Do as much good as you can which can reflect kind, compassionate care above and beyond the minimum, maintaining knowledge and skills, strive for the best interest of the patient etc.
EMRs often require protocols for completion per patient that have nothing to do with their individual care (e.g. inane prompts like assessing suicidal tendencies in a newborn or flu shot status in a trauma victim). They are cumbersome and can make accessing useful information a challenge. Transforming their physician into a data entry specialist by consuming their time erodes the doctor-patient relationship, chips away at things like bedside manner and effective communication that all can impede care. It keeps physicians in the office longer, performing extraneous, routinely redundant tasks on EMRs diminishing the time dedicated to high-quality care. Physicians went to medical school to take care of patients not unnecessarily divert their attention away from them. Since outpatient and inpatient locations as well as differing health centers can have disparate EMRs, given the vast number of companies sourcing them, excessive training and continued education are involuntarily required by staff to remain certified on their respective system. None of these mandatory sessions advance knowledge of disease management or help patients - instead they consume time that could be devoted to such useful skill acquisition or patient care.
Principle of Non-maleficence
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The concept of “first do no harm” is at play here. That risks and benefits are assessed so as the former does not outweigh the latter to create any unnecessary suffering.
EMRs do not speak between institutions which can cause delays in care since health professionals at one place cannot access the data from the other. EMRs routinely exacerbate the difficulty of getting the information. This can further infringe on a person’s ability to choose their doctor given the undue pressure exerted upon them to remain within a hospital system for all of their care even if it is not in their best interest. For example, there could be a more experienced, knowledgeable doctor who is best suited to manage their particular condition at an outside facility.
To sum up
Given that all of these widely accepted (though sometimes debated) principles need to be respected for a medical procedure to be considered ethical, I conclude the implementation of EMRs was a disaster that reverberates to this day. At their best, they added another layer between physician and patient further eroding the relationship and at their worst, they were borderline negligent contributing to a premature exodus of seasoned professionals who had more to give patients and those who came after them professionally.
Under the guise of improving care, they have served as a money grab for competing profit centers at the expense of physicians and patients. With such a recent public focus on Facebook’s misleading policies over use of our data, it will be interesting to see what happens when the spotlight shifts to our protected health information that is currently flying under the radar.
