Cultural Typology V: Personal Relationship with the Patient; an Ethical Conundrum?

The personal relationship between the patient and the physician is the essence of medicine, an ethical relationship based on trust. One could argue that the EHR could challenge privacy and confidentiality, core values of the physician/patient relationship.(1,2) In particular, Rosenthal describes the perception of the physicians that the EHRs are an intrusion into the practitioner-patient relationship.(3) This has also been the case in Israel, an almost fully immersed EMR environment, where physicians use computers in the examination room and report that it can negatively affect patient centered practice. The computer became a “third party” in the clinical encounter requiring particular attention and diminishing the dialogue with the patient, particularly in the psychosocial and emotional realm.(4) In a hospital in Oman, physicians were generally satisfied with EMR, but most of them believed the system did not protect confidentiality because other physicians and nurses could access all clinical notes about patients and the physician could alter what they documented in some sections of the clinical data because it is not protected.(5)

Safeguarding the privacy and confidentiality of patients within the new IT environment, a tremendously volatile environment, poses many problems that are far from being clear, much less resolved.(6) On the one hand, as patients become tech-savvy, they will demand that their physician use current IT options.(7) On the other hand, Lupton would argue that this expectation must be seen within other conflicting expectations; first, frequently physicians are forced to deal with patients’ expectations of their “omnipotence.” Secondly, the physician often does not want to share the uncertainty of their treatment. Last, but critically important, are the demands from hospitals and payers to deal with the patient quickly and efficiently.(8)

To add complexity, the traditional paper chart in the physician’s office allows the physician to maintain certain anonymity, certain invisibility, in terms of what is his/her rationale for the treatment of a patient. The perception by the physician of a possible “oversight” by many others accessing an electronic version of “his” patient’s medical record is a powerful disincentive to the adoption of the EHRs. In addition, one aspect that has was not found addressed in the literature reviewed is that it also challenges the basis of medicine as a trade in which the value of a practice is determined in terms of the number of patient charts (confidential information the physician has of his/her panel of patients) kept in the not-so-easy-to-read paper chart, and locked in a private record room.

In order to address this cultural element, revisiting and, perhaps, redefining the social contract that throughout history society has developed with physicians seem most appropriate at this historical juncture. The EHRs is only pinpointing, like never before, the difficult issue of providing access to the patient of his/her medical information, arguably his/her property.

References:

1. Mackenzie, K., The Key to PHR Success isn’t What You Think. HealthLeaders Media Website. http://www.healthleadersmedia.com/print/content/222765/topic/WS_HLM2_TEC/The-Key-to-PHR-Success-Isnt-What-You-Think.html November 4, 2008. Accessed on November 9, 2008.

2. Simon, SR., Kaushal, R., Cleary, PD., et al. Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey. J Am Med Inform Assoc. 2007;14:110 –117.

3. Rosenthal, DA., Layman, EJ.,  Utilization of Information Technology in Eastern North Carolina Physician Practices: Determining the Existence of a Digital Divide.  Perspectives in Health Information Management 5; 3; Winter 2008 pp.  1-20

4. Margalit, RS., Roter, D., Dunevant, MA., Larson, S., Reis, S., Electronic medical record use and physician–patient communication: An observational study of Israeli primary care encounters. Patient Education and Counseling. Elsevier 2006;61:134–141

5. Farsi, MA., West Jr, DJ., Use of Electronic Medical Records in Oman and Physician Satisfaction. J Med Sys; 2006, 30(1): 17–22

6. GAO, Health Information Technology; Efforts Continue but Comprehensive Privacy Approach Needed for National Strategy. Tuesday, June 19, 2007. www.gao.gov/cgi-bin/getrpt?GAO-07-988T. Downloaded on December 18, 2008

7. Randeree, E., Exploring Physician Adoption of EMRs: A Multi-Case Analysis. J Med Syst. 2007, 31:489–496

8. Lupton, D. Medicine as Culture. Sage, 2nd ed., 2003

Explore posts in the same categories: Culture, Electronic Health Record, Health Information Technologies, Medicine, Physicians

2 Comments on “Cultural Typology V: Personal Relationship with the Patient; an Ethical Conundrum?”

  1. Elga Albino Acosta Says:

    Estimado Dr. Braña, me encanto su enfoque de que la computadora en el momento de la creación del historial médico se convierte en una tercera persona en la sala de evaluación. Entiendo que las notas o historal clínico obtenido y entrado al sistema de EHR, debería tener la opción de que la única persona que pueda alterarlo sea el mismo médico que hizo la entrada, quizás deba ser protegido mediante la entrada de un password asignado a cada médico o mediante el uso de tarjetas de identificación que cuente con el chip que una vez insertada en la computadora solo permite unos limites de acceso específico para cada usuario del sistema. En atención a la insensibilidad y la falta de atención al paciente, en el que alegadamente el médico hace contacto visual mínimo con el paciente. En diversas conferencias y simposios en los que he participado este último año aquí en Puerto Rico, están enfatizando como un proceso de cumplimiento el que el médico tome educaciones continuas para el mejor manejo de dicha situación y que el paciente se sienta más cómodo con el fin de obtener un historial clínico mas confiable. Se dice que el tratamiento óptimo de un paciente esta directamente relacionado en cuan bien el médico pueda obtener la información del paciente que se sienta en confianza.Gracias por su aportación!

    • AngelBranaMD Says:

      Es correcto que la única persona que puede alterar una nota de un proveedor es el proveedor y sería un error de diseño permitir que otra persona cambie algo. Incluso cuando un proveedor hace correcciones hay un registro de metadada que informa quien hizo y cuando lo hizo. El problema que todavía no se ha corregido es como sepresenta el hsitorial de esos cambios en el momento que se hace un último resúmen del estado actual del paciente.


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