Preserving the clinical relationship in the age of digital health

The U.S. health care system is headed toward a profoundly digital future. Provider organizations around the country are adopting and updating their health information technology (HIT) infrastructures. Many have begun requiring that clinicians gain proficiency in electronic health records (EHRs) in order to provide clinical care. A proliferation of start-ups and HIT companies in health care is poised to disrupt (innovatively or not) physician workflow and patient experience.

As a cornerstone of these digital ecosystems, EHRs in particular can fundamentally alter the clinical dynamic between patient and physician. They provide new ways for physicians to communicate with patients and document and bill for medical services. For patients, they represent a vehicle for accessing health information and more actively participating in their own care.

Their positive effects have been well argued and documented. Digital platforms can increase patients' access to clinicians, who can in turn leverage more actionable health data. The ability to share information among clinicians can reduce confusion, error, inefficiency, and cost, while improving quality. Early work suggests that EHRs can empower patients and increase satisfaction and engagement. For example, patients who can access notes written by their primary care physicians report being more engaged in their own care.

With promise, however, comes concern. Some have warned that technology in general may create distance—literal and figurative—between patients and physicians, and in doing so weaken therapeutic bonds. Others believe that despite recent focus on HIT, EHRs may deliver underwhelming gains while introducing unintended ethical influences into the patient-physician relationship. For instance, some emerging data suggest that patients concerned about the privacy of their electronic health data may be more likely to delay seeking care, or even lie to their clinicians.

To be fair, the sole constant in patient-physician relationships is that they are highly contextual. There is great variation in patient populations, clinician traits, practice structures, and care settings, and it would be unfair to generalize any single finding to all clinical situations. As history also reminds us, some ethical concerns turn out to be exactly that: concerns that ultimately remain unsubstantiated. However, unintended consequences are not uncommon amid reform and redesign, a reality that is particularly important for specialties like internal medicine, the practice of which is largely predicated on human connection.

Effective chronic disease management, particularly aspects related to lifestyle habits and behavior, is greatly aided by longitudinal trust between doctors and patients. In many situations, the influence that internists wield arises from confidence and rapport built over time. Even with digital data at a doctor's fingertips, many medical decisions still require the artful application of medical expertise.

To preserve these core aspects of doctoring and clinical relationships, ethical principles (e.g., autonomy, beneficence, nonmaleficence, justice) should be thoughtfully weighed in EHR design and implementation. It is important that this go beyond generalized support for bioethics writ large, which could create more problems than solutions in some situations.

For example, emphasis on patient autonomy has led some in the medical community to call for EHRs that give patients access to and control over their own health data. In the support of patient-centeredness and patients' activation in their own care, this is decidedly good. However, if it occurs at the expense of vital physician access (e.g., by causing harm because clinicians make uninformed decisions based on incomplete or inaccurate information), the practice may run afoul of physicians' commitment to beneficence and non-maleficence. Whether diametrically opposed or not, ethical principles should always be simultaneously considered and blended in EHRs.

A related solution is to create electronic systems designed to account for complexities in patient care, not just those in medical billing. Despite being no small task, this is important given that some have eschewed ethical concerns by arguing that patients have always had the ability and prerogative to lie or withhold health information and that therefore physicians should engage patients, rather than EHRs, to obtain accurate clinical information (i.e., HIT should not substitute for collaborative clinical communication).

While this is true, it fails to account for the reality that EHRs can also make such communication challenging by filling clinical encounters with energy-intensive work around more and more data and clicks. For busy clinicians, culling electronic records for information may be more an issue of necessity and time than of preference. In turn, in conjunction with reforms in payment and organizational structure, HIT approaches that offload data-heavy steps (e.g., via native decision support or incorporation of scribes) in the right settings can provide physicians with the bandwidth to return their attention to what matters: the patient.

Ultimately, there is great promise in the digital future facilitated by EHRs and other technology. However, if these tools are implemented without strong ethical guidance or recognition that they must be designed to preserve elements of the clinical relationship, they may inadvertently counteract high-quality care even as they aspire to promote it.