The Ethical Dilemma Created by EHRs

June 18, 2012

Many of the operational characteristics that are common in today's EHRs encourage dishonest behavior and create a vicious cycle.

Repeated exposure to any noxious stimulus eventually results in desensitization. The American Academy of Pediatrics states that "extensive viewing of television violence by children causes greater aggressiveness." Exposure to TV violence causes the viewers to: become "immune" or numb to the horror of violence; gradually accept violence as a way to solve problems; imitate the violence they observe on television; and identify with certain characters, victims and/or victimizers.

Physicians often find themselves in challenging situations that place extreme demands on their time and attention creating both subtle and overt incentives to act dishonestly. Conflicts arise between their ethical inclinations and reality because there are never enough hours in the day, running a business is fraught with complications, and financial expectations run high. Compromises are inevitable. Some save time by writing illegibly. Some abbreviate liberally. Some use forms that have check-off items that are easy to use - so easy that the physician may check the box even if they only did part of what is implied by the presence of the check mark.

EHRs have not automated healthcare but many have "automated" charting in ways that make it easy to incorporate material in a progress note that is fictitious. Check-boxes have proliferated. Some EHRs will, with a single click, generate a complete and detailed note. Were all those things examined? Was every finding exactly as described? Most physicians would never intentionally lie about things like this, but the EHR can make it so easy. It can be such a time saver. One can understand how a physician might conclude that checking the "normal" box was a reasonable compromise. After all - they did most of it and "believed" that the areas that they skipped were also normal.

Like most computer systems, many EHRs have mandatory fields that must have an entry before the record can be saved. What if the correct answer is in doubt? In order to get the work done, everyone is forced to make a little compromise - enter the most plausible thing that the computer will accept even if it is not strictly true or correct. Eventually the senses get dulled to the point that these compromises no longer evoke an emotional response.

One day the physician is in a hurry and the patient's condition has not changed much (it wasn't expected to have changed) but the insurance company requires a daily progress note. The EHR has a copy/paste function so the physician makes a little compromise and clones yesterday's note, hopefully taking the time to make the appropriate edits but again, the cloned note seems like a pretty good approximation so no edits are made. It's just a little thing - nothing to get upset about.

And so it goes. A compromise here, a compromise there and then calamity strikes. A woman is admitted to the general medicine service and "placed on vancomycin and piperacillin-tazobactam sodium. MRI of the brain was read as suspicious for hemorrhagic metastases, and despite a note from the neurology attending expressing concern about a loud murmur and possible endocarditis." Three weeks later the patient dies, as much from intellectual dishonesty as from the complications of endocarditis.

This is not a new problem. Years ago, I overheard a senior resident instructing a ward team over breakfast: "We can do whatever we want when we're on call as long as we tell the attending what he wants to hear on rounds."

A system that offers incentives to compromise the truth encourages dishonest behavior. A vicious cycle results as people become progressively desensitized to the value of the truth. Today's EHRs do just this by demanding more of the physician's time while simultaneously creating situations that force ethical compromise and by appearing to sanction the compromises by providing features such as copy/paste and one-click normal exams.

Every compromise that one makes has an effect similar to being exposed to violence on television. It dulls the ethical senses a bit. As the discomfort diminishes, the compromises can easily progress from "white lies" to outright lies. The problem is not limited to medicine. It pervades society and the media. Politicians, Wall Street types, political action committees - all are bending the truth or failing to fully disclose it. Sometimes the lying is the cynical and calculated action of sociopaths but more often, lies are told by people that have been forced into compromising situations so frequently that their ethical compasses have been broken or demagnetized; they have simply lost the ability to appreciate the difference between right and wrong.

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