Ethical Implications of the Electronic Health Record: In the Service of the Patient

What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients

BACKGROUND

Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care.

METHODS

At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified.

RESULTS

A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only."

CONCLUSIONS

Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.

Billing for Electronic Patient-Physician Communications: An Ethical Analysis

This review paper analyzes the ethical implications of billing patients for electronic communication with physicians through electronic health records, a practice already adopted by medical institutions such as the Cleveland Clinic. The analysis assesses how billing aligns with pillars of medical ethics which include beneficence, respect for persons, and justice. Although billing may enhance communication, improve patient care, and alleviate physician burnout, concerns arise over potential consequences on patient autonomy, trust, and health care disparities. The review delves into the intricate balance of these ethical principles by first considering the potential benefits of incentivizing concise questions and improving physician workload management through billing. By reducing messages, this approach can potentially mitigate burnout and enhance care. It also acknowledges potential drawbacks such as deterring patients because of financial constraints and eroding trust in physicians and the medical team. It emphasizes the necessity of thoroughly examining all aspects of this intricate ethical dilemma to formulate a nuanced solution that protects patient well-being while respecting physicians. We propose a middle-ground approach involving nominal and transparent billing on the basis of the question's complexity, urgency, and level of expertise required in the response. Transparent billing policies, up-front communication of costs, and potential fee waivers on the basis of socioeconomic status can address equity concerns and maintain patient trust. Striking a balance between the potential benefits and drawbacks of billing for patient questions is crucial in maintaining ethical patient-physician interactions and equitable health care provision. The analysis underscores the importance of aligning online patient-physician communication with ethical principles within the evolving digital health care landscape.

Artificial Intelligence in the Provision of Health Care: An American College of Physicians Policy Position Paper

Internal medicine physicians are increasingly interacting with systems that implement artificial intelligence (AI) and machine learning (ML) technologies. Some physicians and health care systems are even developing their own AI models, both within and outside of electronic health record (EHR) systems. These technologies have various applications throughout the provision of health care, such as clinical documentation, diagnostic image processing, and clinical decision support. With the growing availability of vast amounts of patient data and unprecedented levels of clinician burnout, the proliferation of these technologies is cautiously welcomed by some physicians. Others think it presents challenges to the patient-physician relationship and the professional integrity of physicians. These dispositions are understandable, given the "black box" nature of some AI models, for which specifications and development methods can be closely guarded or proprietary, along with the relative lagging or absence of appropriate regulatory scrutiny and validation. This American College of Physicians (ACP) position paper describes the College's foundational positions and recommendations regarding the use of AI- and ML-enabled tools and systems in the provision of health care. Many of the College's positions and recommendations, such as those related to patient-centeredness, privacy, and transparency, are founded on principles in the ACP Ethics Manual. They are also derived from considerations for the clinical safety and effectiveness of the tools as well as their potential consequences regarding health disparities. The College calls for more research on the clinical and ethical implications of these technologies and their effects on patient health and well-being.

Towards an evaluation framework for medical device-integrated electronic medical record

INTRODUCTION

Medical device (MD)-integrated (I) electronic medical record (EMR) (MDI-EMR) poses cyber threats that undermine patient safety, and thus, they require effective control mechanisms. We reviewed the related literature, including existing EMR and MD risk assessment approaches, to identify MDI-EMR comprehensive evaluation dimensions and measures.

AREAS COVERED

We searched multiple databases, including PubMed, Web of Knowledge, Scopus, ACM, Embase, IEEE and Ingenta. We explored various evaluation aspects of MD and EMR to gain a better understanding of their complex integration. We reviewed numerous risk management and assessment frameworks related to MD and EMR security aspects and mitigation controls and then identified their common evaluation aspects. Our review indicated that previous evaluation frameworks assessed MD and EMR independently. To address this gap, we proposed an evaluation framework based on the sociotechnical dimensions of health information systems and risk assessment approaches for MDs to evaluate MDI-EMR integratively.

EXPERT OPINION

The emergence of MDI-EMR cyber threats requires appropriate evaluation tools to ensure the safe development and application of MDI-EMR. Consequently, our proposed framework will continue to evolve through subsequent validations and refinements. This process aims to establish its applicability in informing stakeholders of the safety level and assessing its effectiveness in mitigating risks for future improvements.

Social, Ethical and Treatment Related Problems Faced by Healthcare Workers in the Care of Head and Neck Cancer Patients: A Narrative Review from the Bioethics Consortium from India

Head and neck cancer (HNC) presents a variety of ethical difficulties for an oncologist involved in screening, diagnosis, treatment, and rehabilitation that are challenging to address, especially for those professionals/people who are not trained in medical ethics. The bioethics department has spent the last ten years compiling information and rating the seriousness of numerous niche ethical concerns and their effects on healthcare professionals practising in India. Based on these findings, the current analysis makes an effort to outline the different challenges faced by oncologists when screening, diagnosing, treating, and rehabilitating people affected with HNC, particularly in a traditional nation like India. According to the authors, this is the first overview to address these issues from an Indian viewpoint, and it represents a small effort to document a crucial but unaddressed component of cancer treatment. It is hoped that these endeavours would aid in educating upcoming healthcare professionals on how to effectively handle the difficulties.

A model to improve user acceptance of e-services in healthcare systems based on technology acceptance model: an empirical study

Improving the quality of electronic services (e-services) is essential when dealing with unforeseen factors and uncertainties in healthcare, such as the outbreak of coronavirus (COVID-19) and changes in the needs and expectations of patients. This paper presents a comprehensive conceptual model in healthcare systems for improving the user acceptance of e-services. A model referred to as the technology acceptance model (TAM) is considered that includes several factors. The factors are computer literacy, website quality, service quality, user attitude, perceived enjoyment, and user satisfaction. According to the collected data and the performed analysis, the fit indices of this survey reveal that the conceptual model has an acceptable fit. The findings are as follows. Computer literacy has positive effects on perceived enjoyment and ease of use. Website quality has positive effects on perceived enjoyment, ease of use, and user satisfaction. Perceived enjoyment has a positive effect on perceived usefulness. Ease of use has positive effects on the usefulness, willingness to use e-services, and user attitude. User satisfaction has a positive effect on user attitude. Perceived usefulness has a positive effect on the willingness to use e-services. Finally, among these variables, only the user attitude has no significant effect on the willingness to use e-services in the healthcare system. Therefore, to promote performance quality and to motivate people to use e-services, healthcare managers should improve these factors.

Insights Into the Relationships Between Health Communication and Doctor-patient Relationship: A Scientometric Analysis Based on CiteSpace and Validation of Questionnaires

In order to understand the research status of the relationship between health communication and doctor-patient relationship, and to explore a new path of the impact of health communication on doctor-patient relationship, this paper adopted qualitative methods to quantize the literature over the past 10 years in the Web of Science database and carried out Co-Authorship Analysis, Co-Citation Analysis and Co-Occurrence Analysis based on CiteSpace. In addition, according to the results of bibliometric research, self-designed questionnaires were used to verify the result. A convenience sampling survey was conducted through the online "Questionnaire Star" platform (https://www.wjx.cn) on May 8, 2022, and a total of 254 questionnaires were collected. Interviewees were asked to use social software to acquire health knowledge. Participants come from 21 provinces, 4 municipalities, and 4 autonomous regions across the country, which is geographically representative. The results show that uncertainty of social media information and the particularity of the epidemic make the research on health communication and doctor-patient relationship in social media become a new hot spot. Social media health information quality (source credibility and content trust perception), information asymmetry perception, doctor-patient communication, doctor-patient consistency, doctor-patient trust, doctor-patient relationship may be the key variables for constructing theoretical models.

Health information technology: Ethical concerns in nursing practice and research

Health information technology (HIT) has become essential for nursing practice. However, the lack of digital literacy leaves some nurses unaware of serious ethical issues that may occur when using it. This article describes the ethical issues that arise with the use of HIT in everyday nursing practice as well as in research activities, and outlines options for mitigation.

Electronic health record implementation and healthcare workers' work characteristics and autonomous motivation-a before-and-after study

Background

Technological innovation in healthcare is often assumed to contribute to the quality of care. However, the question how technology implementation impacts healthcare workers has received little empirical attention. This study investigates the consequences of Electronic Health Record (EHR) implementation for healthcare workers’ autonomous work motivation. These effects are further hypothesized to be mediated by changes in perceived work characteristics (job autonomy and interdependence). Additionally, a moderating effect of profession on the relationship between EHR implementation and work characteristics is explored.

Methods

A quantitative uncontrolled before-and-after study was performed among employees from a large university medical centre in the Netherlands. Data were analysed following the component approach for testing a first stage moderated mediation model, using Generalized Estimating Equations (GEE).

Results

A total of 456 healthcare workers (75 physicians, 154 nurses, 145 allied healthcare professionals, and 82 administrative workers) finished both the baseline and the follow-up survey. After EHR implementation, perceived job autonomy decreased, whereas interdependence increased. In line with our hypothesis, job autonomy was positively associated with autonomous motivation. In contrast to our expectations, interdependence also showed a positive association with autonomous motivation. Autonomous motivation was stable over the course of EHR implementation. This study did not provide support for a moderating effect of profession: no differences were observed between the various professions regarding the changes in their experienced job autonomy and interdependence after EHR implementation.

Conclusions

Our study showed that healthcare professionals’ perceptions of their work characteristics, but not their autonomous motivation, were changed after EHR implementation, and that these experiences were relatively similar for physicians, nurses, and allied healthcare professionals. The stability of healthcare workers’ autonomous motivation may be explained by the opposite effects of decreased job autonomy and increased interdependence, and by the EHR being in line with healthcare workers’ values. The changes in job autonomy and interdependence may have consequences beyond motivation, for example by affecting clinical decision-making, proactive behaviour, and the quality of teamwork. These potential consequences of EHR implementation warrant further research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01858-x.

Toilet-based continuous health monitoring using urine

Regular health monitoring can result in early detection of disease, accelerate the delivery of medical care and, therefore, considerably improve patient outcomes for countless medical conditions that affect public health. A substantial unmet need remains for technologies that can transform the status quo of reactive health care to preventive, evidence-based, person-centred care. With this goal in mind, platforms that can be easily integrated into people's daily lives and identify a range of biomarkers for health and disease are desirable. However, urine - a biological fluid that is produced in large volumes every day and can be obtained with zero pain, without affecting the daily routine of individuals, and has the most biologically rich content - is discarded into sewers on a regular basis without being processed or monitored. Toilet-based health-monitoring tools in the form of smart toilets could offer preventive home-based continuous health monitoring for early diagnosis of diseases while being connected to data servers (using the Internet of Things) to enable collection of the health status of users. In addition, machine learning methods can assist clinicians to classify, quantify and interpret collected data more rapidly and accurately than they were able to previously. Meanwhile, challenges associated with user acceptance, privacy and test frequency optimization should be considered to facilitate the acceptance of smart toilets in society.

An Ethical Case for Medical Scribes

This article addresses ethical concerns with the use of electronic health records (EHRs) by physicians in clinical practice. It presents arguments for two claims. First, requiring physicians to maintain patient EHRs for medically unnecessary tasks is likely contributing to increased burnout, decreased quality of care, and potential risks to patient safety. Second, medical institutions have ethical reasons to employ medical scribes to maintain patient EHRs. Finally, this article reviews central objections to employing medical scribes and provides responses to each.

Not another box to check! Using the UTAUT to explore nurses' psychological adaptation to electronic health record usability

BACKGROUND

As the integration of electronic health records (EHRs) continues to expand throughout healthcare organizations worldwide, nurses are faced with the challenge to acclimate to a dynamic technology-based environment of patient care. As technology advances, EHR usability may influence nurses' clinical performance and require nurses to adapt to a wide range of situations associated with electronic documentation. While perceived benefits of EHRs include improvements in healthcare delivery and patient outcomes, there are also unintended consequences associated with EHR usability.

AIMS

The aim of this article is to explore dimensions of EHR usability that may influence nurses' psychological adaptation to the use of EHRs in daily practice.

MATERIALS AND METHODS

The unified theory of acceptance and use of technology (UTAUT) consists of four constructs theorized to have a direct influence on end-user behavior and acceptance of technology: performance expectancy, effort expectancy, social influence, and facilitating conditions. The UTAUT provides the framework to explore EHR usability as found in literature and describe the positive and negative psychological responses of nurses related to the use of EHRs in daily practice.

RESULTS

Integration of EHRs into daily nursing practice can result in positive experiences or have a negative impact on nurses ability to perform their role as patient caregivers.

DISCUSSION

While integration of EHRs into healthcare systems can facilitate improvements in patient outcomes, the delivery of patient care and nurses' daily practices can simultaneously be complicated by EHR usability issues.

CONCLUSION

Although positive and negative experiences of nurses in relationship to EHR usability can be found in literature, there is limited evidence on nurses' psychological adaptation to use of EHRs. Further research on EHR usability is needed based on nursing perspectives and feedback to determine the psychological impact EHRs exert on nurses, discover effective methods for resolving issues, and promote positive trends associated with EHR usability.

Assessing Health Data Security Risks in Global Health Partnerships: Development of a Conceptual Framework

Background

Health care databases contain a wealth of information that can be used to develop programs and mature health care systems. There is concern that the sensitive nature of health data (eg, ethnicity, reproductive health, sexually transmitted infections, and lifestyle information) can have significant impact on individuals if misused, particularly among vulnerable and marginalized populations. As academic institutions, nongovernmental organizations, and international agencies begin to collaborate with low- and middle-income countries to develop and deploy health information technology (HIT), it is important to understand the technical and practical security implications of these initiatives.

Objective

Our aim is to develop a conceptual framework for risk stratification of global health data partnerships and HIT projects. In addition to identifying key conceptual domains, we map each domain to a variety of publicly available indices that could be used to inform a quantitative model.

Methods

We conducted an overview of the literature to identify relevant publications, position statements, white papers, and reports. The research team reviewed all sources and used the framework method and conceptual framework analysis to name and categorize key concepts, integrate them into domains, and synthesize them into an overarching conceptual framework. Once key domains were identified, public international data sources were searched for relevant structured indices to generate quantitative counterparts.

Results

We identified 5 key domains to inform our conceptual framework: State of HIT, Economics of Health Care, Demographics and Equity, Societal Freedom and Safety, and Partnership and Trust. Each of these domains was mapped to a number of structured indices.

Conclusions

There is a complex relationship among the legal, economic, and social domains of health care, which affects the state of HIT in low- and middle-income countries and associated data security risks. The strength of partnership and trust among collaborating organizations is an important moderating factor. Additional work is needed to formalize the assessment of partnership and trust and to develop a quantitative model of the conceptual framework that can help support organizational decision-making.

Qualitative Examination of Shared Decision-Making in Canada's Largest Health System: More Work to be Done : Shared Decision-Making-More Work to be Done

Background: Shared Decision-Making (SDM) is an inclusive approach where patients and providers work in partnership to make health care decisions that are grounded in clinical best practice and align with patient preferences and values. Despite a growing recognition that SDM can lead to improved outcomes and reductions in unnecessary health investigations, tensions exist between patient agency and a historically paternalistic model of health care. As an evolving ideology, the Research Team sought to better understand the current state, challenges, and implementation opportunities of SDM practices across the health system. Methods: This study used a cross-sectional quality improvement design utilizing semistructured interviews to gather information from focus group participants. Five open-ended, qualitative questions were used to generate discussion on the perceptions of SDM and its role in clinical appropriateness in a variety of clinical contexts in our health system. A total of 12 focus groups (n = 95 participants) representative of patients and families, leaders, physicians, and frontline clinicians were engaged in the study. Results: Through a consensus-based approach, study results identified 4 recommendations based on 4 themes: Time, Communication, System Design, and Clinical Appropriateness. Conclusion: There are no easy solutions to the challenges of enabling SDM; however, success will be dependent upon recognizing the importance of patient agency, while maintaining an inclusive and continuous stakeholder engagement with both patients and providers. Implementation of the 4 recommendations at the organizational level highlighted in this study can serve as a road map for other health care institutions and will require a gradual approach to transform the general principles of SDM into tangible solutions to meet the emerging needs at both the local and system level.

Characterizing Multitasking and Workflow Fragmentation in Electronic Health Records among Emergency Department Clinicians: Using Time-Motion Data to Understand Documentation Burden

BACKGROUND

The impact of electronic health records (EHRs) in the emergency department (ED) remains mixed. Dynamic and unpredictable, the ED is highly vulnerable to workflow interruptions.

OBJECTIVES

The aim of the study is to understand multitasking and task fragmentation in the clinical workflow among ED clinicians using clinical information systems (CIS) through time-motion study (TMS) data, and inform their applications to more robust and generalizable measures of CIS-related documentation burden.

METHODS

Using TMS data collected among 15 clinicians in the ED, we investigated the role of documentation burden, multitasking (i.e., performing physical and communication tasks concurrently), and workflow fragmentation in the ED. We focused on CIS-related tasks, including EHRs.

RESULTS

We captured 5,061 tasks and 877 communications in 741 locations within the ED. Of the 58.7 total hours observed, 44.7% were spent on CIS-related tasks; nearly all CIS-related tasks focused on data-viewing and data-entering. Over one-fifth of CIS-related task time was spent on multitasking. The mean average duration among multitasked CIS-related tasks was shorter than non-multitasked CIS-related tasks (20.7 s vs. 30.1 s). Clinicians experienced 1.4 ± 0.9 task switches/min, which increased by one-third when multitasking. Although multitasking was associated with a significant increase in the average duration among data-entering tasks, there was no significant effect on data-viewing tasks. When engaged in CIS-related task switches, clinicians were more likely to return to the same CIS-related task at higher proportions while multitasking versus not multitasking.

CONCLUSION

Multitasking and workflow fragmentation may play a significant role in EHR documentation among ED clinicians, particularly among data-entering tasks. Understanding where and when multitasking and workflow fragmentation occurs is a crucial step to assessing potentially burdensome clinician tasks and mitigating risks to patient safety. These findings may guide future research on developing more scalable and generalizable measures of CIS-related documentation burden that do not necessitate direct observation techniques (e.g., EHR log files).

Writing Practices Associated With Electronic Progress Notes and the Preferences of Those Who Read Them: Descriptive Study

Background

Hospital progress notes can serve as an important communication tool. However, they are criticized for their length, preserved content, and for the time physicians spend writing them.

Objective

We aimed to describe hospital progress note content, writing and reading practices, and the preferences of those who create and read them prior to the implementation of a new electronic health record system.

Methods

Using a sample of hospital progress notes from 1000 randomly selected admissions, we measured note length, similarity of content in successive daily notes for the same patient, the time notes were signed and read, and who read them. We conducted focus group sessions with note writers, readers, and clinical leaders to understand their preferences.

Results

We analyzed 4938 inpatient progress notes from 418 authors. The average length was 886 words, and most were in the Assessment & Plan note section. A total of 29% of notes (n=1432) were signed after 4 PM. Notes signed later in the day were read less often. Notes were highly similar from one day to the next, and 26% (23/88) had clinical risk associated with the preserved content. Note content of the highest value varied according to the reader’s professional role.

Conclusions

Progress note length varied widely. Notes were often signed late in the day when they were read less often and were highly similar to the note from the previous day. Measuring note length, signing time, when and by whom notes are read, and the amount and safety of preserved content will be useful metrics for measuring how the new electronic health record system is used, and can aid improvements.

Defining current gaps in quality measures for cancer immunotherapy: consensus report from the Society for Immunotherapy of Cancer (SITC) 2019 Quality Summit

BACKGROUND

Quality measures are important because they can help improve and standardize the delivery of cancer care among healthcare providers and across tumor types. In an environment characterized by a rapidly shifting immunotherapeutic landscape and lack of associated long-term outcome data, defining quality measures for cancer immunotherapy is a high priority yet fraught with many challenges.

METHODS

Thus, the Society for Immunotherapy of Cancer convened a multistakeholder expert panel to, first, identify the current gaps in measures of quality cancer care delivery as it relates to immunotherapy and to, second, advance priority concepts surrounding quality measures that could be developed and broadly adopted by the field.

RESULTS

After reviewing the existing quality measure landscape employed for immunotherapeutic-based cancer care, the expert panel identified four relevant National Quality Strategy domains (patient safety, person and family-centered care, care coordination and communication, appropriate treatment selection) with significant gaps in immunotherapy-based quality cancer care delivery. Furthermore, these domains offer opportunities for the development of quality measures as they relate to cancer immunotherapy. These four quality measure concepts are presented in this consensus statement.

CONCLUSIONS

This work represents a first step toward defining and standardizing quality delivery of cancer immunotherapy in order to realize its optimal application and benefit for patients.

Patients' moral attitudes toward electronic health records: Survey study with vignettes and statements

Patient access to electronic health records gives rise to ethical questions related to the patient-doctor-computer relationship. Our study aims to examine patients' moral attitudes toward a shared EHR, with a focus on autonomy, information access, and responsibility. A de novo self-administered questionnaire containing three vignettes and 15 statements was distributed among patients in four different settings. A total of 1688 valid questionnaires were collected. Patients' mean age was 51 years, 61% was female, 50% had a higher degree (college or university), and almost 50% suffered from a chronic illness. Respondents were hesitant to hide sensitive information electronically from their care providers. They also strongly believed hiding information could negatively affect the quality of care provided. Participants preferred to be informed about negative test results in a face-to-face conversation, or would have every patient decide individually how they want to receive results. Patients generally had little experience using patient portal systems and expressed a need for more information on EHRs in this survey. They tended to be hesitant to take up control over their medical data in the EHR and deemed patients share a responsibility for the accuracy of information in their record.

Oncology patients' perception of physicians who use an integrated electronic health record (EHR) during clinic visits: PRIME-EHR double-blind, randomized controlled trial

BACKGROUND

Patients with cancer prefer and positively perceive physicians who communicate face-to-face without the use of a computer. However, the use of electronic health records (EHRs) in the examination room remains a practical necessity. On the basis of existing literature, the authors developed and tested an integration model, PRIME-EHR, that focuses on the best-practice guidelines. To their knowledge, no randomized controlled trials (RCTs) have been conducted to test the effectiveness of such models.

METHODS

In this double-blind, crossover RCT, 120 eligible patients with cancer were enrolled between April 1, 2019 and February 15, 2020 at The University of Texas MD Anderson Cancer Center. The objectives were to compare patients' perceptions of physicians' skills and their overall preference after they watched 2 standardized, scripted video vignettes of physicians: 1 portraying the use of a standard EHR and the other portraying the use of a PRIME-EHR. Actors and patients were blinded to the purpose of the study. Investigators were blinded to the sequence of videos watched by the patients. Validated questionnaires to rate physicians' compassion (0 = best, 50 = worst), communication skills (14 = poor, 70 = excellent), and professionalism (4 = poor, 20 = very good) were used.

RESULTS

PRIME-EHR, compared with the standard EHR, resulted in better scores for physician compassion (median score, 5 [interquartile range, 0-10] vs 12 [interquartile range, 4-25]; P = .0009), communication skills (median score, 69 [interquartile range, 63-70] vs 61 [interquartile range, 50-69]; P = .0026), and professionalism (median score, 20 [interquartile range, 18-20] vs 18 [interquartile range, 14-20]; P = .0058). The majority of patients preferred physicians who used PRIME-EHR (n = 70 [77%] vs n = 21 [23%]; P < .0001).

CONCLUSIONS

The PRIME-EHR approach significantly improved patients' perceptions of and preference for the physicians. This integrated model of health care delivery has the potential to improve communication and compassion in cancer care.

Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians

Technologic advancements and the evolving digital health landscape have offered innovative solutions to several of our health care system's issues as well as increased the number of digital interactions and type of personal health information that is generated and collected, both within and outside of traditional health care. This American College of Physicians' position paper discusses the state of privacy legislation and regulations, highlights existing gaps in health information privacy protections, and outlines policy principles and recommendations for the development of health information privacy and security protections that are comprehensive, transparent, understandable, adaptable, and enforceable. The principles and recommendations aim to improve on the privacy framework in which physicians have practiced for decades and expand similar privacy guardrails to entities not currently governed by privacy laws and regulations. The expanded privacy framework should protect personal health information from unauthorized, discriminatory, deceptive, or harmful uses and align with the principles of medical ethics, respect individual rights, and support the culture of trust necessary to maintain and improve care delivery.

The role of undergraduate medical students training in respect for patient confidentiality

BACKGROUND

Encouraging professional integrity is vital for providing a standard of excellence in quality medical care and education and in promoting a culture of respect and responsibility. The primary objective of this work consisted of studying the relationship of medical students to the right to patient privacy in Spain, specifically by analysing the conditions for accessing patient clinical histories (CHs).

METHODS

A cross-sectional study was conducted based on a questionnaire sent by e-mail to final-year students at 41 Spanish universities. It had 14 multiple choice and closed questions framed in 3 large blocks. The first question addressed basic general knowledge issues on the right to privacy and the obligation for confidentiality. The two remaining blocks were made up of questions directed towards evaluating the frequency with which certain requirements and action steps related to students attending patients were performed and regarding the guarantees associated with accessing and handling patient CHs both on paper and in the Electronic Medical Record.

RESULTS

A total of 245 valid replies were considered. A total of 67.8 % of participants were women, with an average age of 24.05 ± 3.49 years. Up to 90.6 % were aware that confidentiality affected the data in CHs, although 43.3 % possessed non-anonymized photocopies of patient clinical reports outside the healthcare context, and only 49.8 % of the students were always adequately identified. A total of 59.2 % accessed patient CHs on some occasions by using passwords belonging to healthcare professionals, 77.2 % of them did not have the patients' express consent, and 71.9 % accessed a CH that was not anonymised.

CONCLUSIONS

The role of healthcare institutions and universities is considered to be fundamental in implementing educational measures regarding the risks and ethical and legal problems arising from the use of CHs among professionals and students. A thorough study of medical ethics is needed through the analysis of clinical cases and direct exposure to situations in which the patient's confidentiality is questioned.

Vulnerable patients' attitudes towards sharing medical data and granular control in patient portal systems: an interview study

BACKGROUND

The collection, storage and exchange of medical information are becoming increasingly complex. More parties are involved in this process, and the data are expected to serve many different purposes beside patient care. This raises several ethical questions regarding privacy, data ownership, security and confidentiality. It is vital to consider patients' moral attitudes and preferences in this digital information exchange. The voice of vulnerable patients is rarely heard in research addressing these questions. This study aims to address this void.

METHOD

Fourteen vulnerable patients without prior experience with patient portal systems were interviewed for this study. First, participants were introduced to the portal and given time to read their personal medical data. Afterwards, semi-structured interviews were conducted and analysed thematically to explore participants' first experience with the portal and their views on sharing medical information with care providers and other parties.

RESULTS

Data analysis resulted in four themes: barriers to and benefits of portal access, emotional responses to reading medical information, diverging views on sharing information with third parties and balancing granular control and the best possible care. First, participants appreciated access to their health information in the portal despite experiencing obstacles. Second, reading medical information online could evoke emotional responses. Third, patients were generally unaware of the meaning and value of medical data to third parties, resulting in inconsistent views on data sharing. Finally, although patients generally supported granular control, they were willing to give up on their autonomy if that would ensure them to receive the best possible care.

CONCLUSIONS

Patient portal design should take into consideration the obstacles that discourage vulnerable patients' access and hamper meaningful use. There is a need for more transparency on secondary use of medical data by third parties. Patients should be better informed about the potential consequences of sharing data with them.

"EMERGing" Electronic Health Record Data Metrics: Insights and Implications for Assessing Residents' Clinical Performance in Emergency Medicine

OBJECTIVES

Competency-based medical education requires that residents are provided with frequent opportunities to demonstrate competence as well as receive effective feedback about their clinical performance. To meet this goal, we investigated how data collected by the electronic health record (EHR) might be used to assess emergency medicine (EM) residents' independent and interdependent clinical performance and how such information could be represented in an EM resident report card.

METHODS

Following constructivist grounded theory methodology, individual semistructured interviews were conducted in 2017 with 10 EM faculty and 11 EM residents across all 5 postgraduate years. In addition to open-ended questions, participants were presented with an emerging list of EM practice metrics and asked to comment on how valuable each would be in assessing resident performance. Additionally, we asked participants the extent to which each metric captured independent or interdependent performance. Data collection and analysis were iterative; analysis employed constant comparative inductive methods.

RESULTS

Participants refined and eliminated metrics as well as added new metrics specific to the assessment of EM residents (e.g., time between signup and first orders). These clinical practice metrics based on data from our EHR database were organized along a spectrum of independent/interdependent performance. We conclude with discussions about the relationship among these metrics, issues in interpretation, and implications of using EHR for assessment purposes.

CONCLUSIONS

Our findings document a systematic approach for developing EM resident assessments, based on EHR data, which incorporate the perspectives of both clinical faculty and residents. Our work has important implications for capturing residents' contributions to clinical performances and distinguishing between independent and interdependent metrics in collaborative workplace-based settings.

The usability of Jordan stillbirths and neonatal deaths surveillance (JSANDS) system: results of focus group discussions

Background

Jordan Stillbirths and Neonatal Deaths Surveillance system (JSANDS) is a newly developed system and is currently implemented in five large hospitals in Jordan. This study aimed at exploring the healthcare professionals’ perception about the usability of JSANDS.

Methods

A descriptive qualitative approach, using focus group discussions, was adopted. A total of 5 focus groups including 23 focal points were conducted in five participating hospitals in Jordan.

Results

Data analysis identified nine main issues related to the JSANDS system: the system usefulness, the system performance, data quality, the system limitations, human rights, female empowerment, nurses’ competencies strengthened, the sustainability of the JSANDS, and COVID-19 impact on the system. Users reported that JSANDS data were useful, the system was simple and easy to use, and the data were accurate and complete. However, some users reported that some technical issues need to be enhanced.

Conclusions

JSANDS was perceived positively by the current users. According to them, it provides a formative and comprehensive data on stillbirths and neonatal deaths and their causes, and therefore, was recommended to be adopted by its users and scaled up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00551-1.

The anatomy of electronic patient record ethics: a framework to guide design, development, implementation, and use

BACKGROUND

This manuscript presents a framework to guide the identification and assessment of ethical opportunities and challenges associated with electronic patient records (EPR). The framework is intended to support designers, software engineers, health service managers, and end-users to realise a responsible, robust and reliable EPR-enabled healthcare system that delivers safe, quality assured, value conscious care.

METHODS

Development of the EPR applied ethics framework was preceded by a scoping review which mapped the literature related to the ethics of EPR technology. The underlying assumption behind the framework presented in this manuscript is that ethical values can inform all stages of the EPR-lifecycle from design, through development, implementation, and practical application.

RESULTS

The framework is divided into two parts: context and core functions. The first part 'context' entails clarifying: the purpose(s) within which the EPR exists or will exist; the interested parties and their relationships; and the regulatory, codes of professional conduct and organisational policy frame of reference. Understanding the context is required before addressing the second part of the framework which focuses on EPR 'core functions' of data collection, data access, and digitally-enabled healthcare.

CONCLUSIONS

The primary objective of the EPR Applied Ethics Framework is to help identify and create value and benefits rather than to merely prevent risks. It should therefore be used to steer an EPR project to success rather than be seen as a set of inhibitory rules. The framework is adaptable to a wide range of EPR categories and can cater for new and evolving EPR-enabled healthcare priorities. It is therefore an iterative tool that should be revisited as new EPR-related state-of-affairs, capabilities or activities emerge.

Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review

OBJECTIVE

Despite the widespread and increasing use of electronic health records (EHRs), the quality of EHRs is problematic. Efforts have been made to address reasons for poor EHR documentation quality. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or paper documentation. The purpose of this systematic review was to assess the effectiveness of interventions seeking to improve EHR documentation within an inpatient setting.

MATERIALS AND METHODS

A search strategy was developed based on elaborated inclusion/exclusion criteria. Four databases, gray literature, and reference lists were searched. A REDCap data capture form was used for data extraction, and study quality was assessed using a customized tool. Data were analyzed and synthesized in a narrative, semiquantitative manner.

RESULTS

Twenty-four studies were included in this systematic review. Owing to high heterogeneity, quantitative comparison was not possible. However, statistically significant results in interventions and affected outcomes were analyzed and discussed. Education and implementation of a new EHR reporting system were the most successful interventions, as evidenced by significantly improved EHR documentation.

DISCUSSION

Heterogeneity of interventions, outcomes, document type, EHR user, and other variables led to difficulty in measuring EHR documentation quality and effectiveness of interventions. However, the use of education as a primary intervention aligned closely with existing literature in similar fields.

CONCLUSIONS

Interventions implemented to enhance EHR documentation are highly variable and require standardization. Emphasis should be placed on this novel area of research to improve communication between healthcare providers and facilitate data sharing between centers and countries.

PROSPERO Registration Number: CRD42017083494.

Interprofessional Evidence-Based Strategies to Enhance Provider and Patient Interactions During Electronic Health Record Use

The purpose of this study was to develop and disseminate evidence-based interprofessional strategies to enhance provider-patient interactions, including ethical issues, that arise during electronic documentation. An interprofessional simulation scenario was implemented with students, and strategies developed were then used to train hospital staff. Nurses reported being significantly more likely to use the interprofessional strategies after completing the program. Interprofessional simulation and training is an effective method to address challenges that arise during electronic health record use.

Relationship Between Burnout and Professional Behaviors and Beliefs Among US Nurses

OBJECTIVE

To evaluate the relationship between burnout and professional behaviors and beliefs among US nurses.

METHODS

We used data from 2256 nurses who completed a survey that included the Maslach Burnout Inventory and items exploring their professional conduct (documented something they had not done so they could "close out" an encounter in the EHR or part of the assessment not completed, requested continuing education credit for an activity not attended) and beliefs about reporting impaired colleagues.

RESULTS

On multivariable analysis, burnout was independently associated with higher odds of reporting 1 or more unprofessional behaviors in the last year and not believing nurses have a duty to report impairment among colleagues due to substance use or mental health problems.

CONCLUSIONS

Occupational burnout is associated with self-reported unprofessional behaviors and less favorable beliefs about reporting impaired colleagues among nurses.

American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations

Communication is critical to strong patient-physician relationships and high-quality health care. In recent years, advances in health information technology have altered how patients and doctors interact and communicate. Increasingly, e-communication outside of in-person clinical encounters occurs in many ways, including through e-mail, patient-portals, texting, and messaging applications. This American College of Physicians (ACP) position paper provides ethics and professionalism guidance for these forms of e-communication to help maintain trust in patient-physician relationships and the profession and alignment between patient and physician expectations.

Examination and diagnosis of electronic patient records and their associated ethics: a scoping literature review

Background

Electronic patient record (EPR) technology is a key enabler for improvements to healthcare service and management. To ensure these improvements and the means to achieve them are socially and ethically desirable, careful consideration of the ethical implications of EPRs is indicated. The purpose of this scoping review was to map the literature related to the ethics of EPR technology. The literature review was conducted to catalogue the prevalent ethical terms, to describe the associated ethical challenges and opportunities, and to identify the actors involved. By doing so, it aimed to support the future development of ethics guidance in the EPR domain.

Methods

To identify journal articles debating the ethics of EPRs, Scopus, Web of Science, and PubMed academic databases were queried and yielded 123 eligible articles. The following inclusion criteria were applied: articles need to be in the English language; present normative arguments and not solely empirical research; include an abstract for software analysis; and discuss EPR technology.

Results

The medical specialty, type of information captured and stored in EPRs, their use and functionality varied widely across the included articles. Ethical terms extracted were categorised into clusters ‘privacy’, ‘autonomy’, ‘risk/benefit’, ‘human relationships’, and ‘responsibility’. The literature shows that EPR-related ethical concerns can have both positive and negative implications, and that a wide variety of actors with rights and/or responsibilities regarding the safe and ethical adoption of the technology are involved.

Conclusions

While there is considerable consensus in the literature regarding EPR-related ethical principles, some of the associated challenges and opportunities remain underdiscussed. For example, much of the debate is presented in a manner more in keeping with a traditional model of healthcare and fails to take account of the multidimensional ensemble of factors at play in the EPR era and the consequent need to redefine/modify ethical norms to align with a digitally-enabled health service. Similarly, the academic discussion focuses predominantly on bioethical values. However, approaches from digital ethics may also be helpful to identify and deliberate about current and emerging EPR-related ethical concerns.

Patient Privacy Violation Detection in Healthcare Critical Infrastructures: An Investigation Using Density-Based Benchmarking

Hospital critical infrastructures have a distinct threat vector, due to (i) a dependence on legacy software; (ii) the vast levels of interconnected medical devices; (iii) the use of multiple bespoke software and that (iv) electronic devices (e.g., laptops and PCs) are often shared by multiple users. In the UK, hospitals are currently upgrading towards the use of electronic patient record (EPR) systems. EPR systems and their data are replacing traditional paper records, providing access to patients’ test results and details of their overall care more efficiently. Paper records are no-longer stored at patients’ bedsides, but instead are accessible via electronic devices for the direct insertion of data. With over 83% of hospitals in the UK moving towards EPRs, access to this healthcare data needs to be monitored proactively for malicious activity. It is paramount that hospitals maintain patient trust and ensure that the information security principles of integrity, availability and confidentiality are upheld when deploying EPR systems. In this paper, an investigation methodology is presented towards the identification of anomalous behaviours within EPR datasets. Many security solutions focus on a perimeter-based approach; however, this approach alone is not enough to guarantee security, as can be seen from the many examples of breaches. Our proposed system can be complementary to existing security perimeter solutions. The system outlined in this research employs an internal-focused methodology for anomaly detection by using the Local Outlier Factor (LOF) and Density-Based Spatial Clustering of Applications with Noise (DBSCAN) algorithms for benchmarking behaviour, for assisting healthcare data analysts. Out of 90,385 unique IDs, DBSCAN finds 102 anomalies, whereas 358 are detected using LOF.

Role of Health Information Technology in Addressing Health Disparities: Patient, Clinician, and System Perspectives

Over the last decade, health information technology (IT) has dramatically transformed medical practice in the United States. On May 11-12, 2017, the National Institute on Minority Health and Health Disparities, in partnership with the National Science Foundation and the National Health IT Collaborative for the Underserved, convened a scientific workshop, "Addressing Health Disparities with Health Information Technology," with the goal of ensuring that future research guides potential health IT initiatives to address the needs of health disparities populations. The workshop examined patient, clinician, and system perspectives on the potential role of health IT in addressing health disparities. Attendees were asked to identify and discuss various health IT challenges that confront underserved communities and propose innovative strategies to address them, and to involve these communities in this process. Community engagement, cultural competency, and patient-centered care were highlighted as key to improving health equity, as well as to promoting scalable, sustainable, and effective health IT interventions. Participants noted the need for more research on how health IT can be used to evaluate and address the social determinants of health. Expanding public-private partnerships was emphasized, as was the importance of clinicians and IT developers partnering and using novel methods to learn how to improve health care decision-making. Finally, to advance health IT and promote health equity, it will be necessary to record and capture health disparity data using standardized terminology, and to continuously identify system-level deficiencies and biases.

An Experience of Electronic Health Records Implementation in a Mexican Region

Employing software engineering to build an integrated, standardized, and scalable solution is closely associated with the healthcare domain. Furthermore, new diagnostic techniques have been developed to obtain better results in less time, saving costs, and bringing services closer to the most unprotected areas. This paper presents the integration of a top-notch component, such as hardware, software, telecommunications, and medical equipment, to produce a complete system of Electronic Health Record (EHR). The EHR implementation aims to contribute to the expansion of the health services offer concerning people who live in locations where typically have difficult access to medical care. The methodology throughout the work is a Strategic Planning to set priorities, focus energy and resources, strengthen operations, ensure that directors, managers, employees, and other stakeholders are working toward common goals, establish agreement around intended outcomes/results. A medical and technical team is incorporated to complete the tasks of process and requirements analysis, software coding and design, technical support, training, and coaching for EHR system users throughout the implementation process. The adoption of those tools reflect notably some expected results and benefits on patient care. The EHR implementation ensures that information collection does not duplicate already existing information or duplicate effort and maximize the practical use of the data collected. Moreover, the EHR reduces mistakes in hospital readmissions, improves paperwork, promotes the progress of the state's health care system providing emergency, specialty, and primary health care in a rural area of Campeche. The EHR implementation is critical to support decision making and to promote public health. The total number of consults increased markedly from 2012 (14021) to 2019 (34751). The most commonly treated diseases in this region of Mexico are hypertension (17632) and diabetes (13156). The best results are obtained in the Nutrition (20,61%) and clinical psychology services (16,67%), and the worst levels are registered in pediatric and surgical oncology services where only 1,59% and 1,97% of the patients are admitted in less than 30 min, respectively.

Rethinking the electronic health record through the quadruple aim: time to align its value with the health system

Electronic health records (EHRs) are considered as a powerful lever for enabling value-based health systems. However, many challenges to their use persist and some of their unintended negative impacts are increasingly well documented, including the deterioration of work conditions and quality, and increased dissatisfaction of health care providers. The “quadruple aim” consists of improving population health as well as patient and provider experience while reducing costs. Based on this approach, improving the quality of work and well-being of health care providers could help rethinking the implementation of EHRs and also other information technology-based tools and systems, while creating more value for patients, organizations and health systems.

Psychiatric electronic health records privacy in Jordan: A policy brief

Psychiatric health records are highly sensitive data which requires special policy to maintain its privacy, without affecting data accessibility. The current authors reviewed social, ethical and legal underpinnings for psychiatric electronic health records (EHR), and suggests a policy to maintain privacy and confidentiality of the psychiatric data, without affecting data accessibility. The purpose of this policy brief is to discuss and provide alternatives regarding psychiatric electronic health records privacy and information access. The current policy applied in Jordan still immature to ensure high levels of reliability, as the psychiatric data is openly accessed to the non-specialized personnel. Sensitive personal data policy is recommended in this paper with developing overriding mechanisms to counteract obstacles to data accessibility.

Narrative Review for Exploring Barriers to Readiness of Electronic Health Record Implementation in Primary Health Care

Objectives

The aim of this study is to explore the enabling factors associated with readiness in Electronic Health Record (EHR) implementation and to identify the barriers related to readiness regarding the situation of primary health cares in developed and developing countries.

Methods

A narrative review of open-source literature was conducted using the ProQuest, ScienceDirect, MEDLINE, and PMC databases to identify the enabling factors and barriers to EHR readiness. The keywords applied were 'electronic health record', 'readiness', 'primary health care', and 'primary care'.

Results

Some barriers were found that may affect readiness, specifically individual barriers and organizational barriers. In developing countries, organizational barriers such as a lack of skilled manpower, insufficient senior management, and a lack of interaction among team members were the common barriers, while in developed countries individual barriers such as unfamiliarity with new systems and a lack of time to use computers were frequently found as barriers to readiness.

Conclusions

This study summarized the enabling factors and barriers with regard to EHR readiness in developed and developing countries.

Reconceptualizing the Electronic Health Record for a New Decade: A Caring Technology?

Since the 2009 publication by Petrovskaya et al on, "Dilemmas, Tetralemmas, Reimagining the Electronic Health Record," and passage of the Health Information Technology for Economic Clinical Health (HITECH) Act, 96% of hospitals and 78% of providers have implemented the electronic health record. While many positive outcomes such as guidelines-based clinical decision support and patient portals have been realized, we explore recent issues in addition to those continuing problems identified by Petrovskaya et al that threaten patient safety and integrity of the profession. To address these challenges, we integrate polarity thinking with the tetralemma model discussed by Petrovskaya et al and propose application of a virtue ethics framework focused on cultivation of technomoral wisdom.

Protecting healing relationships in the age of electronic health records: report from an international conference

We present findings of an international conference of diverse participants exploring the influence of electronic health records (EHRs) on the patient–practitioner relationship. Attendees united around a belief in the primacy of this relationship and the importance of undistracted attention. They explored administrative, regulatory, and financial requirements that have guided United States (US) EHR design and challenged patient-care documentation, usability, user satisfaction, interconnectivity, and data sharing. The United States experience was contrasted with those of other nations, many of which have prioritized patient-care documentation rather than billing requirements and experienced high user satisfaction. Conference participants examined educational methods to teach diverse learners effective patient-centered EHR use, including alternative models of care delivery and documentation, and explored novel ways to involve patients as healthcare partners like health-data uploading, chart co-creation, shared practitioner notes, applications, and telehealth. Future best practices must preserve human relationships, while building an effective patient–practitioner (or team)-EHR triad.

Using Electronic Health Record Data to Assess Residents' Clinical Performance in the Workplace: The Good, the Bad, and the Unthinkable

PURPOSE

Novel approaches are required to meet assessment demands and cultivate authentic feedback in competency-based medical education. One potential source of data to help meet these demands is the electronic health record (EHR). However, the literature offers limited guidance regarding how EHR data could be used to support workplace teaching and learning. Furthermore, given its sheer volume and availability, there exists a risk of exploiting the educational potential of EHR data. This qualitative study examined how EHR data might be effectively integrated and used to support meaningful assessments of residents' clinical performance.

METHOD

Following constructivist grounded theory, using both purposive and theoretical sampling, in 2016-2017 the authors conducted individual interviews with 11 clinical teaching faculty and 10 senior residents across 12 postgraduate specialties within the Schulich School of Medicine and Dentistry at Western University. Constant comparative inductive analysis was conducted.

RESULTS

Analysis identified key issues related to affordances and challenges of using EHRs to assess resident performance. These include the nature of EHR data; the potential of using EHR data for assessment; and the dangers of using EHR data for assessment. Findings offer considerations for using EHR data to assess resident performance in appropriate and meaningful ways.

CONCLUSIONS

EHR data have potential to support formative assessment practices and guide feedback discussions with residents, but evaluators must take context into account. The EHR was not designed with the purpose of assessing resident performance; therefore, adoption and use of these data for educational purposes require careful thought, consideration, and care.

An exploratory study of digital workforce competency in Thailand

Industry 4.0 and the digital age have dramatically influenced both information technology (IT) job characteristics and IT labor demand. Leaders in higher education must keep up with the situation and accelerate plans to produce graduates with the quality and preparation required to meet industry needs. But based on the existing demand gap, universities are eager to first know which skills the IT-related industries expect from new digital workers. This study, conducted in Thailand, explores the competency of the digital workforce, an issue that was identified as vital to the 2017-2021 national agenda. The research project was divided into two steps. Phase one was to study and identify essential competencies for the digital workforce by first reviewing the literature, then verifying these results through qualitative methodology. Thirty IT experts in IT and related industries were invited to interview sessions. Eventually, after content analysis, 24 competencies were presented. Phase two was to survey the competency expectations of IT experts by using the initial questions generated by Phase One's outcome. 260 questionnaires were analyzed. Exploratory factor analysis (EFA) was selected to cluster the digital workforce competencies that were found. Three significant categories were selected based on Eigenvalue, and the average results of demand were explained. Industries had most expected competencies in the Professional skills and IT knowledge category, followed by the IT technical category and IT management and support category. The top five competencies desired were lifelong learning, personal attitude, teamwork, dependability, and IT foundations. However, there were some slightly different requirements between the IT industry and IT in non-IT industries. The results presented a new perspective that is very useful to Thailand. The academic sector can use these results to shape IT curriculum in order to effectively respond to real demand. In addition, recent graduates or graduating students can study these conclusions and better prepare themselves for future jobs.

Nurses' Perception of the Impact of Electronic Documentation on the Nurse-Patient Relationship

BACKGROUND

While there are many benefits of electronic medical record documentation, the presence of a computer may adversely affect provider-patient interaction.

PURPOSE

The purpose of this project was to examine staff nurses' perception of the impact of electronic documentation in the presence of the patient on the nurse-patient relationship.

METHODS

A survey was administered to 276 staff nurses, and open-ended interviews were conducted with 11 novice and 20 expert nurses.

RESULTS

Nurses identified benefits and challenges to electronic medical record documentation as well as strategies used to maintain therapeutic relationships and communication. Numerous nurses commented that documenting with their back to the patient had a negative impact on the nurse-patient relationship and communication.

CONCLUSIONS

Both novice and expert nurses identified strategies that they used to ensure they were "maintaining the connection" to patients during electronic medical record documentation.

American College of Physicians Ethics Manual: Seventh Edition

Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The seventh edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.

Precision medicine in COPD: where are we and where do we need to go?

Chronic obstructive pulmonary disease (COPD) was the fourth leading cause of death worldwide in 2015. Current treatments for patients ease discomfort and help decrease disease progression; however, none improve lung function or change mortality. COPD is heterogeneous in its molecular and clinical presentation, making it difficult to understand disease aetiology and define robust therapeutic strategies. Given the complexity of the disease we propose a precision medicine approach to understanding and better treating COPD. It is possible that multiOMICs can be used as a tool to integrate data from multiple fields. Moreover, analysis of electronic medical records could aid in the treatment of patients and in the predictions of outcomes. The Precision Medicine Initiative created in 2015 has made precision medicine approaches to treat disease a reality; one of these diseases being COPD.

Using voice to create inpatient progress notes: effects on note timeliness, quality, and physician satisfaction

Objectives

We describe the evaluation of a system to create hospital progress notes using voice and electronic health record integration to determine if note timeliness, quality, and physician satisfaction are improved.

Materials and methods

We conducted a randomized controlled trial to measure effects of this new method of writing inpatient progress notes, which evolved over time, on important outcomes.

Results

Intervention subjects created 709 notes and control subjects created 1143 notes. When adjusting for clustering by provider and secular trends, there was no significant difference between the intervention and control groups in the time between when patients were seen on rounds and when progress notes were viewable by others (95% confidence interval -106.9 to 12.2 min). There were no significant differences in physician satisfaction or note quality between intervention and control.

Discussion

Though we did not find support for the superiority of this system (Voice-Generated Enhanced Electronic Note System [VGEENS]) for our 3 primary outcomes, if notes are created using voice during or soon after rounds they are available within 10 min. Shortcomings that likely influenced subject satisfaction include the early state of our VGEENS and the short interval for system development before the randomized trial began.

Conclusion

VGEENS permits voice dictation on rounds to create progress notes and can reduce delay in note availability and may reduce dependence on copy/paste within notes. Timing of dictation determines when notes are available. Capturing notes in near-real-time has potential to apply NLP and decision support sooner than when notes are typed later in the day, and to improve note accuracy.

Electronic Health Record Use Among American Neurotology Society Members

OBJECTIVE

To describe the use of electronic health records (EHR) among members of the American Neurotology Society (ANS).

STUDY DESIGN

Cross-sectional.

SETTING

Active ANS members in November 2017.

INTERVENTION

Internet-based survey.

MAIN OUTCOME MEASURE

Survey that assessed the use of EHR in practice, types of EHR programs, different elements of EHR employed, and respondents' satisfaction and efficiency with EHR.

RESULTS

One hundred twenty-seven ANS members responded to the survey with 67 (52.8%) respondents working in academic practice and 60 (47.2%) respondents working in private practice. Epic was the most commonly used EHR with 89 (70.1%) respondents using this system. Among all respondents, 84 (66.1%) respondents reported their efficiency was reduced by EHR use, and there was an even split between respondents who reported they were satisfied versus dissatisfied with their EHR (∼40% each). We found that younger members were more likely to feel EHR increased their efficiency compared with the older members (p = 0.04). In all other analyses, we found no significant difference in efficiency and satisfaction between age groups, practice settings, presence of residents or fellows, or specific EHR used. The main challenges reported by ANS members related to the EHR were increased time burden, poor user interface, lack of customizability, and the focus away from patients.

CONCLUSIONS

The majority of ANS members felt their efficiency decreased as a result of EHR. These findings provide specific changes to the EHR that would improve efficiency and satisfaction among neurotologists.

Heeding humanity in an age of electronic health records: Heidegger, Levinas, and Healthcare

The American Recovery and Reinvestment Act of 2009 (ARRA) required healthcare providers in the United States to adopt and demonstrate meaningful use of electronic health records (EHRs) by January 1, 2014. In many ways, EHRs mark a notable improvement over paper medical records as they are more easily accessible and allow for electronic searching and sharing of medical history. However, as EHRs have become mandated by ARRA, many nurses now rely upon computers far more heavily during nurse-patient interactions, thereby decreasing the level of direct interpersonal communication between the two. There is evidence that eye contact between nurses and patients positively affects patient satisfaction. Above and beyond the issue of patient satisfaction is the more basic ethical issue of respecting the patient as a person. The author argues that the templates used in electronic health systems have the possibility of eroding the respect for humanity that is the hallmark of nurse-patient relationships, as signalled by the American Nurses Association's first principle in their Code of Ethics. Using concepts from philosophers Martin Heidegger and Emmanuel Levinas, the author provides guidance as to what an ethical interaction between nurse and patient should look like in an age of EHRs.

Transitions From Acute Care to Long-Term Care: Evaluation of the Continued Access Model

Improving communication during transitions from acute care hospitals into long-term post-acute care (LTPAC) settings is imperative for clinical staff to have the information they need to admit and care for the patient with accurate medical information provided in an efficient way. The research goals of this study are to examine the user experience of a new data sharing method, "Continued Access," a supplement to the standard summary of care, and to evaluate staff attitudes of the model on LTPAC residents' care. Clinical staff ( n = 20) from a U.S. Midwestern LTPAC setting were interviewed to give their evaluation of the new model of data access, their concerns, and ways to improve the effectiveness of the model. Respondents reported better opportunities for quality care based on improved insight and clarity around patients' medical history, medications, and tests. Strategies for integrating Continued Access into the workflow and improving quality outcomes are discussed.