Traditional philosophical ethics has taught that ethical behavior is either cultivated by repetitive activities or a matter of learning the ethical rules and then choosing to follow them for their own intrinsic “rightness.” While both of these theories probably are partially correct, empirical ethicists have shown that, in general, we are more or less likely to behave ethically depending on the context in which we face the ethical question.
In an experimental scenario, for example, even seminarians were more likely to behave like the “Good Samaritan” when they were not running late to the church where they were expected to give a sermon on…the story of the Good Samaritan.1 So if we want ethical behavior, it is reasonable to try to make behaving ethically easier than behaving unethically.
Unfortunately, I think many electronic medical records (EMRs) function in a way that actually encourages physicians to behave unethically. I’m not suggesting that this excuses unethical behavior. Hopefully, we could become more cognizant of these hidden incentives to stray and be especially vigilant of our choices while working on an EMR.
Following are 2 examples of the potential ethical dangers of EMRs, but I suspect in the comments, there will be others that I have not considered.
Sitting at breakfast at the recent APGO conference (Association of Professors of Gynecology and Obstetrics), one attendee noted how with his institution’s new EMR, all the new gynecology notes included that “cranial nerves were tested and are intact.” He joked that not only was he sure they hadn’t been tested but also that his colleagues no longer even knew how to test them.
Similarly, I remember discovering that when I checked “all normal” on our new Ob module, included in that module was a fundoscopic exam that I do not do. I discovered this months after having checked “all normal” many times. It may not be unethical to inadvertently misrepresent your exam, but it certainly is unethical to knowingly misrepresent your exam. However, it’s easier to check “all normal” than individually check every box in the exam, and I have no ability to individualize my exam template. I suspect the same is true with the cranial nerve exam—it may be part of the “all normal” template, and it’s just easier to “fudge” a little.
Choosing the path of least resistance is one reason that the EMR may not reflect what was actually done in the exam room. The ability to “up code” a visit by just checking more boxes is also now being dangled in front of us—more check marks can equal a higher visit level of coding and more reimbursement. While this was always possible, the EMR actually facilitates this.
I suspect we have all seen patients in consultation who, upon questioning, deny that the exam detailed in great specificity in the EMR ever took place. For some reason, it requires a greater degree of dishonest intent to dictate an exam that never happened than to simply check a box for a history or exam item that had not actually been performed.
The other problem with structured, menu-driven notes may seem more innocuous than my first complaint, but I believe it ultimately may be more destructive to the doctor-patient relationship. Since this relationship is at the heart of what it means to be an ethical physician, using structured notes presents an ethical challenge to our specialty.
Here’s why: structured notes are generic—they all look alike—and the differences between different EMRs are more evident in reading these notes than the differences between patients.
I have read structured notes on patients of mine that I know well, and I couldn’t recognize my patient in the note unless she had some unusual medical condition. The person completely disappears, especially when the social history is the following: tobacco +/–, etoh +/–, and partner status.
I have encouraged our residents who use the structured note function to “freehand” enough detail about the patient so that they will recognize her when she returns. Perhaps there are EMRs out there that do a better job of personalizing their notes, but I have not had the pleasure to work with one—or even read a note from one.
I am not a Luddite who believes we should go back to some kind of “old time medicine,” but I think the EMR has been designed with a primary goal of increasing physician efficiency. Efficiency is obviously valuable, but it is one value among many that must be upheld by good medical practitioners.
A technology that encourages physicians to exaggerate their histories and exams and to generate a generic note that looks the same for every patient has pushed us farther from the real goals of medicine. I believe this can be fixed without abandoning the advantages of the technology, but we will have to make honest, compassionate medical care a priority over speed and maximizing our billing.
1. Appiah KA. Experimental philosophy. Presented at: Presidential Address, Eastern Division APA, December 2007. Available at: http://www.lightforcenetwork.com/sites/default/files/Experimental%20Philosophy%20-%20Kwame%20A.%20Appiah.pdf. Accessed January 15, 2014.