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.