Ethics Corner

Christian P. DiPaola, MD
Ethics & Professionalism Committee Member

The Electronic Medical Record (EMR) and the doctor-patient relationship

The evolution of the Electronic Medical Record (EMR) has profoundly impacted medical care. Along with the benefits of newer EMRs, such as legibility, near instantaneous transmission of information, and remote access, come unintended consequences such as data entry errors and information distortion.

Ofri (2019) stated that “It is true that health care has become corporatized to an almost unrecognizable degree. But it is also true that most clinicians remain committed to the ethics that brought them to the field in the first place.”¹ If the corporatization of medicine is a disease, then the EMR by analogy, is the chemo-therapy. While the stated goals of the EMR are “for good”, the administration of it carries potential “harm” to the patient and to the doctor-patient relationship.¹

In this piece, we’ll focus on the effect that the “cut and paste” feature of the EMR has on our documentation, that being to extract phrases, data, pre-populated notes, and carry them forward into a new document to represent a physician’s own medical documentation of a doctor-patient interaction. It is this function that leads to the routine generation of 4-6 page progress notes, 20-50+ page discharge summaries, and tremendous chart redundancy. Here are four potential risks associated with this medical record “cut and paste” function.

Legal risk

According to Snyder-Sulmasy (2017), “Cut and paste without attribution may perpetuate inaccuracies and could, in some instances, potentially constitute fraud. The risks of cut and paste can outweigh its benefits; and it should be used judiciously. Cutting and pasting can lead to lengthy extraneous information from previous entries, as does template driven importation of data.”² Anti-plagiarism software exists, and could be utilized, to protect academic integrity by deciphering original content from what is cut and pasted. While it is not illegal or unethical to be unoriginal, the cut and paste feature exposes the physician/surgeon to increased legal scrutiny when clear patterns of documentation either propagate errors or appear so exactly similar that one is left to question their veracity.

Trust

The EMR cut and paste function could potentially erode the trust of our patients, particularly if our documentation practice relies on pre-populated statements that do not reflect the interactions and conversations that we had with our patients. Patients have easier access to their medical records today than ever before, and can recognize errors or references to questions that clearly were not discussed in the encounter. These errors may be pre-populated statements to cover a “documentation requirement”. Patients have changed doctors because of this in an effort to find someone who they “felt was actually listening to them.” Indiscriminate use of EMR functions create the potential to erode doctor-patient trust.

Scale/error propagation risk

The risk of error propagation can result from the cut and paste function, and again imparts legal risks to professionals. Yaneer Bar-Yam (2004) found two key problems with automation: correct implementation and an effective user interface. If the system is not implemented correctly, the system can make many errors. And, if the application or interface is not done correctly there can be many errors that occur at the first step of the process, when the equipment is instructed what to do.” Automation reduces the likelihood of random mistakes occurring in the steps that have been automated, but may introduce problems at the starting point and through hard-to-find errors in implementation.³

For example, in a real setting, a physician consultant reviewed an EMR’s numerous notes from primary care doctors and other consultants, which appeared comprehensive and lengthy (4-6 pages in length). When he discussed the patient’s past surgical history, he was told of four previous surgeries. Strangely, each of the many notes from the same EMR system stated “past surgical history-none on file”. It was definitely true (no surgery was on file). But, it did not represent the true history of the patient, and had been carried through to every note subsequently.

Risk to information fidelity (signal vs. noise)

The substantial volume of data produced in the EMR as a result of cut and paste leads to a “signal versus noise” problem in which there is too much information to sift through in order to formulate a reasonable understanding of the patient’s condition. Extensive (>100 pages) discharge summaries are not unheard of, and can lead to a patient record that fails to communicate effectively.

In summary, Snyder-Sulmasy’s report on the ethical implications of the EMR found that the copy and paste function is often encouraged. This might save 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.² Focusing on features in the patient’s initial presentation early in the diagnostic process can lead to the cognitive bias of “anchoring “where the initial impression is not adjusted, or even given new information. Smart phrases and templates may prompt narrowing of the diagnostic horizon”.²

Kuhn et al. (2015) developed a consensus statement for the American College of Physicians-“The primary goal of EHR generated documentation should be concise history rich notes.”⁴ Today’s version of the EMR (with widespread use of the cut and paste function) often departs from this goal.

Although the EMR is intended to provide better care for the patient, these systems are designed to capture data in “boxes, columns and rows”. The data is meant to be organized and easily searched for processing and repackaging. Information has become “categorical” rather than “continuous” for the sake of the database, and critical information can be lost in the process.

We must emphasize accuracy in the medical record as one method of maintaining trust in the physician-patient relationship.

References

1. Ofri, D.  The Business of Health Care Depends on Exploiting Doctors and Nurses- One resource seems infinite and free: the professionalism of caregivers.  New York Times.  June 8, 2019.
2. Snyder-Sulmasy, L; Lopez, A; Horwitch, C.  Ethical Implications of the Electronic Health Record: In the Service of the Patient. Journal of General Internal Medicine. Aug; 32(8):935-939.  2017
3. Bar-Yam,Y.  Making Things Work.  Solving complex problems in a complex world.  Healthcare II; Medical Errors.  Knowledge Press.  2004
4. Kuhn, T; Bausch, P; Barr, M; Yackel T.  Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med.  162: 301-3.  2015.

 

Chair: B. Stephens Richards III Committee: Kamal N. Ibrahim, Past Chair; James M. Eule; Timothy A. Garvey; H. Robert Tuten; Christian P. DiPaola (C); Sang D. Kim (C); Olavo B. Letaif (C); Jonathan N. Sembrano (C); Paulo J. Silva Ramos (C); Bekir Y. Ucar (C); Anthony M. Petrizzo; Jochen P. Son-Hing; Jacob M. Buchowski; David A. Hanscom; Steven D. Glassman, Chair Elect; Sherif M. El Ghamry; Hee-Kit Wong