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Reconceptualizing the Electronic Health Record for a New Decade

A Caring Technology?

Robichaux, Catherine PhD, RN; Tietze, Mari PhD, RN-BC, FHIMSS; Stokes, Felicia JD, MA, RN; McBride, Susan PhD, RN-BC, CPHIMS, FAAN

doi: 10.1097/ANS.0000000000000282
Original Articles
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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.

University of Mary, Bismarck, North Dakota and UT Health, San Antonio, Texas (Dr Robichaux); Texas Woman's University, Dallas (Dr Tietze); American Nurses Association, Silver Spring, Maryland (Dr Stokes); and Health Sciences Center, Texas Tech University, Lubbock (Dr McBride).

Correspondence: Catherine Robichaux, PhD, RN, 2541 Gramercy Park Dr, Flower Mound, TX 75028 (robichaux@uthscsa.edu).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

IN 2009, Petrovskaya et al1 maintained that uncritical acceptance of the electronic health record (EHR) in nursing posed a threat to ethical practice. The authors asserted that EHR technology prioritized institutional goals of standardization and cost efficiency, and was incompatible with the caring goals of nursing to provide a good for individuals and society. To move beyond this technology versus caring dilemma, Petrovskaya et al1 introduced the Buddhist notion of the tetralemma. Rather than conceptualizing a dilemma as an “either/or,” the tetralemma expands the choice of possibilities, thus avoiding a foregone conclusion or choice.1 This approach also promotes reflection on the positive aspects of seemingly negative options.

Our purpose in this critique and innovation article is to examine the continuing challenges discussed by Petrovskaya et al and recent issues with the use and design of the EHR.1 Similar to the 2009 article, our focus is the EHR with mention of many other electronic technologies such as mobile applications and patient portals, which are now used in patient care delivery.2

We propose to integrate the notion of polarity thinking with the tetralemma and identify current and potential issues that impact both patient safety and the integrity of the nursing profession. These include optimization of the EHR, clinical decision support systems, sentinel events, and situations leading to moral distress due to technology, burnout, and provider fatigue. Petrovskaya et al1 provide a strong foundation for this dialogue/critique with a need to update the discussion due to emerging issues after the passage of the Health Information Technology for Economic Clinical Health (HITECH) Act of 2009.3

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Statement of Significance

What is known or assumed to be true about this topic:

In 2009, Petrovskaya et al identified several problematic issues with the EHR that impacted ethical nursing practice including use of standardized language and labeling. To transcend the dilemma posed by the EHR and this caring-versus-technology issue, the authors proposed application of the tetralemma. The tetralemma encourages consideration of all aspects of an issue, positive and negative, thus avoiding an either/or foregone choice. This reimagining of the dilemma contributes to reenvisioning the EHR, not as a priority, but as a technology used in and for patient care.

What this article adds:

Although many positive aspects of the EHR have been realized following passage of the HITECH Act in 2009, situations impacting patient safety and integrity of the nursing profession continue to arise. We examine several recent issues in addition to those continuing problems discussed by Petrovskaya et al and propose consideration of polarity thinking as an adjunct to the tetralemma. Application of a virtue ethics framework and cultivation of technomoral wisdom, the ability to effectively respond to the moral demands of existing and emerging technologies, is proposed. To conclude, we provide recommendations for policy, practice, education, and research to address these challenges and associated ethical issues with the EHR and technology innovations.

We apply a virtue ethics framework supported by cultivation of technomoral wisdom. We explore how this approach, and reconceptualization of the EHR as a caring technology, may supersede the dualism discussed by Petrovskaya et al.1 The overemphasis on technology rather than “care” devalues the human interaction often creating challenges with fully delivering and documenting a fundamental component of nursing practice constituting “caring.” To conclude, we suggest recommendations for policy, practice, education, and research to address the emerging challenges and associated ethical issues with technology innovations in the health care industry.

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CONCEPTUALIZING THE EHR

Background

As technology advances, electronic methods of collecting and storing health care information have become more prevalent and beneficial to organizations. Health care organizations are no exception, as they move toward completely electronic systems to store patient records and other pertinent information, in a way that can be shared between patients, hospitals, physicians, and different medical practices. Through the use of electronic medical records (EMRs), health care providers have easier access to essential patient information.4 Two points of clarification are needed, however. First, the term EMR is sometimes used interchangeably with EHR. There is a slight distinction, but the more common term used for an electronic documentation system for patient medical information is the EHR.5 An EMR contains the medical and treatment history of the patients in one practice. EHRs cover all that the EMR can do and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider's office and inclusive of a broader view on a patient's care.5 The term “EHR” has been used in this article to reflect electronic documentation in a patient record.

EHRs have changed the way traditional medical records are housed and managed. The digital way of maintaining patient medical records has shaped the health care industry by allowing providers to keep all information in one place, as well as easily share records between offices of providers. These systems are relatively new, and as organizations work to implement the systems, the way EHRs are used will continue to change and evolve.5

The specific components for consideration are addressed by the Agency for Healthcare Research and Quality, where it is noted that EHRs can improve the quality and safety of health care. The adoption and effective use of health information technology can:

  • Help reduce medical errors and adverse events.
  • Enable better documentation and file organization.
  • Provide patients with information that assists their adherence to medication regimens and scheduled appointments.
  • Assist doctors in tracking their treatment protocols.4
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Policy formation

The EHR as conceptualized under the HITECH Act of 2009 is to establish the digital highway for standardized quality data to improve quality, cost, and the overall health of the nation. To establish the health care information technology (HIT) infrastructure for the digital highway, the HITECH Act was passed in 2009 as part of the American Recovery and Reinvestment Act. The HITECH Act and accompanying Centers for Medicare & Medicaid Services incentive program, formerly entitled “Meaningful Use,” established financial incentives that resulted in aggressive and rapid adoption of certified EHRs that met the requirements for meaningful use, including structures and standards to establish the digital highway for the electronic exchange of data.6 One important example of this requirement was to create an ability to capture and report in near real-time electronic clinical quality measures (eCQMs).6

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CURRENT STATUS OF THE EHR TECHNOLOGY

HITECH Act

In many respects, the overarching goal of the HITECH Act has been realized with 96% of hospitals and 78% of providers having adopted and implemented a certified EHR.7 Although impressive, these improvements in EHR adoption present challenges with optimizing certified technology within institutions and across regions, states, and the nation. The adoption of EHR technology is only one step toward the effective use of HIT for which advanced practice nurses will have to play a major role. Given this massive update in HIT infrastructure across the United States, now the goal to fully implement our nation's national health care strategy is to maximize and achieve returns on investments for organizations focused on improvement strategies to effectively utilize EHRs.8 Compounding this goal is the recent body of evidence, indicating that the HITECH Act EHR as originally conceptualized has resulted in usability, interoperability issues, and burden of documentation for clinicians.9,10 Additional evidence suggests that these challenges within the clinical workflow of teams providing care often result in moral distress.9,11

A number of articles published in the mid-2000s addressed the potential risks that EHRs posed to patient confidentiality and losing the patient- or person-centeredness.1,12,13 Yet, these articles failed to predict the potential harm of EHRs to nurses and other health care professionals. A review of the current literature reveals an increase in provider burnout and distress related to the use of EHRs creating the burden of documentation, as well as the potential for patient safety issues due to poorly designed or implemented EHRs.10,14

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Unintended consequences

In 2012, the committee on patient safety and health information technology explored what progress had been made since the initial report by the Institute of Medicine in 1999.15,16 Findings indicated that some improvements had occurred, but much more was needed. However, it was noted that:

  • Health IT can improve patient safety in some areas such as medication safety; however, there are significant gaps in the literature regarding how health IT impacts patient safety overall.
  • Safer implementation and use begins with viewing health IT as part of a larger sociotechnical system.
  • All stakeholders need to work together to improve patient safety.15

This report drove researchers to further explore causes of error and led to the notion of the associated “unintended consequences” of health information technology.16 In other words, sometimes, we do not even know that patient harm is occurring. Such initial findings were based on the research from the Provider Order Entry Team of the Oregon Health and Science University. In review of thousands of provider orders, errors could now begin to be categorized by type and degree of harm. In addition, however, researchers were able to present the best practices they identified to help organizations overcome these various errors.16

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Clinical decision support and unintended consequences

The Office of the National Coordinator for Health Information Technology (ONC) defines clinical decision support as “a process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient-specific interventions, assessments, recommendations, or other forms of guidance that are then presented to a decision making recipient or recipients that can include clinicians, patients, and others involved in care delivery.”17 Many of the benefits upon which the HITECH Act was conceptualized related to drug-drug and drug-allergy alerts, as well as alerts for critical decision points within recommended clinical guidelines. Yet, these same clinical decision support alerts can have unintended consequences by overalerting clinicians resulting in alert fatigue, dissatisfaction with the use of EHRs, and workarounds resulting in patient safety issues. These issues negate the value generated by the technology. To address these issues, end-user satisfaction evaluating and feedback is essential.

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Burden of documentation

Evidence is now suggesting that the certified EHR as originally conceptualized is resulting in a burden of documentation and undue stressors for clinicians. As a result, the 21st Century Cures Act18 includes provisions that address deficiencies in interoperability and the approach taken to adopt certified EHRs under the HITECH Act. The bill instructs the ONC to develop public-private partnerships in an effort to create “trusted exchange frameworks.” These frameworks include a common agreement among networks of health care organizations. In addition, the ONC is working with the National Institute of Standards and Technology and other federal agencies to ensure interoperability that includes network-to-network health information exchange. The bill also requires that a strategy be developed to address the burden of documentation. In addition, the National Academy of Medicine has designed a conceptual model of factors affecting clinician well-being and resilience including factors that result from stressors resulting from an overemphasis on technology rather than patient-/person-centric caring.19

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Standardizing language/labeling

In this critique, we examine health information technology innovations that pose a risk of harm, despite the intended benefit. Petrovskaya et al1 suggest that data entered into the EHR by nurses should be recorded and stored in a standardized manner to influence reimbursement and enhance communication between nurses and other health care professionals. Discussions regarding standardization of language have evolved and vastly expanded from those simply regarding nursing taxonomy and nursing diagnosis. The EHR creates a situation where the nurse must consider the meaningful use of words and language that is not arduous to document, accurately captures the individual patient-centered experience, allows for optimization of the EHR for high-quality outcomes, and protects patient privacy and confidentiality. Nurses continue to grapple with issues regarding accurately capturing the patient's narrative, but also face daily challenges within the EHR such as documentation of accurate narrative notes and patient autonomy in the use and control over their health information.

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Narrative notes

Nurses are often in a unique position to fully capture the patient's narrative due to the proximity of time spent with the patient, as well as the development of trust that is fundamental in the nurse-patient relationship. However, the EHR has challenged a nurse's ability to timely and accurately capture the patient's narrative. Nurses report challenges in reporting the patient's full story because the EHR user interface requires scrolling through numerous menus and pages that takes away from the workflow and the therapeutic relationship. For example, nurses face limitations in charting narrative explanations of outlying vital signs or interventions that only offer an automated recording of the results often imported from a separate program such as a medication administration device or vital signs monitor. This disruption in the workflow may cause nurses to perform “workarounds” to achieve positive and more efficient outcomes for themselves to fully capture the patient's true narrative.14 As a result, nurses are forced to chart some information in the EHR but write other information on paper when charting in the EHR at a later time.

Nurses also report feeling that the implementation of the EHR detracts from the caring nature of the profession by forcing them to decide between high-quality patient care and regulatory or documentation requirements, also identified by Petrovskaya et al. A nurse in one study described frustration with the EHR stating, “I hated my job that day and was left feeling like the EMR [electronic medical record] was a measure of just how poor of a nurse I was.”1(pE9). Petrovskaya et al identify the narrow-viewed culture that data are more important than a patient's true narrative. The implementation of the EHR seems to usurp the nurse's ability to describe the patient's biophysiological, behavioral, emotional and cognitive responses to illness and intervention. This raises important considerations for how the EHR captures the patient's true narrative from the perspective of the nurse, patient, collaboratively, or otherwise.1

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NEW POSSIBILITIES FOR THE EHR

Autonomy in the use and control of health information

There is tremendous public interest in the use and management of health-related information.20 Advanced technology now allows patients to track, view, and even share their health information on personal wearable devices, mobile devices, and computers. Patients are investing time and money for access and engagement with their health information and desire personalization of data for a meaningful experience.20 This personalization respects patient autonomy and allows for customization of their health experience and information.

Health information exchanges can contain patient diagnoses, prognosis, medications, treatment plans, and test results often used by insurance companies and health care professionals.21 In addition, many health care professionals have adopted patient portals. Patient portals are electronic health information exchanges that also allow patients to view medical information including secure messaging and scheduling appointments.22 Patient portals allow patients to feel empowered and are beneficial in the management of chronic disease processes.

Research suggests that people of color, older age, unmarried, and low socioeconomic status are at risk of not adopting the use of the patient portal.22,23 These patients may be more likely to activate their patient portal with in-person technological assistance. These findings suggest that nurses and other health care professionals should have adequate resource allocation to support patients at risk of not adopting the patient portal or benefitting from the use of the patient portal but to perform individual assessments of usability to avoid assumptions, such as age, in offering these tools to patients.22

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Cultivating technomoral wisdom

The tetralemma approach offers an expanded space of options in decision-making and provides a way to move beyond the dualistic “either/or” of caring versus technology dilemma posed by the EHR.1 Similarly, polarity thinking encourages consideration of how a focus on one pole (the EHR) without attention to the second pole, the ethical mandate of caring, may result in a negative outcome. The Figure illustrates how the tetralemma and polarity thinking, depicted in the overarching umbrella, can be applied to issues associated with the EHR represented by smaller umbrellas. For example, in considering a documentation issue, such as the use of standardized language versus narrative notes the tetralemma enables us to move beyond the either/or dilemma and consider other choices that are both increased in number and suggest “a way to hold together seemingly contradictory ideas.”1(p.24)

Figure

Figure

The dilemma posed by use of standardized language or narrative notes can become both, and/or, or perhaps in the future, evolve into another synergistic choice. As a complementary approach, polarity thinking is a method of considering a problem or dilemma in which either/or decisions are also supplemented with both/and thinking. Polarities are independent pairs or poles, which need each other over time to gain performance and to achieve a higher purpose. While positive results can be obtained from focusing on one pole, such as timely documentation, negative outcomes, or unintended consequences, may occur when there is not enough attention to the other pole, patient-centered care.24

Although many positive aspects of the EHR have been realized since 2009, challenges to provider integrity and delivery of quality care, as addressed in previous sections, have proliferated. Many of these concerns will require a redesign of the EHR to address usability issues, “a global concern for healthcare providers.”10(p191) Integrating the tetralemma with polarity thinking may enhance clarity and creativity in decision-making when encountering such issues. Recognizing and addressing their ethical implications, however, requires attention to the character, wisdom, and actions of those involved, components of virtue ethics.

Several authors have discussed the relevance of virtue ethics25,26 and wisdom27 in nursing practice. Nelson, however, defines the latter in relation to information technology as “the appropriate use of data, information, and knowledge in making decisions and implementing nursing actions. It includes the ability to integrate data, information, and knowledge with professional values when managing specific human problems.”28(p1) Individual data, evaluated against the nurse's knowledge, can assist the nurse to act ethically on that knowledge, illustrating nursing wisdom. As Matney et al27 note, “Wisdom and ethics are attributes of each other ... as they share the characteristics of judgment, caring, and responsibility.”27(p1) This wisdom is expressed through professional expertise and compassionate actions that are appropriate to the situation and congruent with the patient's worldview.

In Technology and the Virtues,29 Vallor describes a virtue ethics framework in which integration of what she describes as technomoral virtues manifest as technomoral wisdom, the ability to effectively respond to the moral demands of existing and emerging technologies. These virtues are grounded in the classical traditions of Aristotelian virtue ethics, Buddhism, and Confucianism. Unlike principle or duty-based ethics, virtue ethics does not focus on rules for good or bad actions but rather on the qualities or virtues of morally exceptional individuals. Many of the technomoral virtues Vallor explores are familiar to nurses. However, she presents them in a new light by emphasizing what they mean in a technosocial context, one in which technological powers are integrated within social practices, values, and institutions.29

Of particular relevance to the current discussion, and to reconceptualizing or revisioning the EHR as a caring technology, are technomoral humility, empathic concern and caring, justice, and leadership. In nursing, “caring technology” is described by Locsin and Ito30 within a theoretical framework as “Technological Competency as Caring in Nursing”30 with the ultimate purpose of technological competency as caring requiring that nurses “know persons as caring who are participants in their care, rather than simply objects of care.”30(p5) In this mid-range theory, caring and technology are not viewed within a binary frame but seen as coexisting with the mutual goal of furthering health and the quality of care.

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Humility

In 2009, Petrovskaya et al noted that “many articles that address the role of the EHR in nursing maintain a cheerful tone and do not problematize the use of the EHR.”1 The subsequent unintended consequences and ethical issues presented in previous sections of this article may compel us to embrace the technomoral virtue of humility, “a recognition of the limits of our technosocial knowledge and ability.” Technomoral humility is not overly pessimistic or optimistic, but a critical intermediate assessment of our technological abilities and creative powers. Exercise of this virtue would mitigate the uncritical assumption that any technological innovation is essentially worthwhile, justified, and can be “fixed” by more and better technology or processes. An example, although not a technological “fix,” is the use of workarounds, “addressing a perceived block in workflow by informally revising the process to get around the blockage.”31(p36)

While intentions behind their use may be beneficent and promote innovation, workarounds can have negative consequences for patient safety and quality care. Several authors have also discussed the ethical implications of workarounds for both the nurse and the organization. These include erosion of professional integrity, moral distress, and turnover.24 Stutzer and Rushton32 cite statements from The Code of Ethics for Nurses with Interpretive Statements relevant to workarounds including the nurse's obligation to communicate EHR safety issues, and the nurse leader's mandate to create an ethical practice environment in which those issues are heard and addressed.33

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Empathic concern and caring

The cultivation of technomoral empathy, expressed as empathic concern, is dependent upon an ability to read emotional cues from the faces and bodies of others and is mediated by the virtue of self-control, which serves to limit distraction.29 While EHRs enhance documentation of legible and accurate information, as noted by Petrovskaya et al, they also serve as a source of distraction, diverting the nurse's (providers') attention away from the patient. This distraction is compounded by associated time pressures in providing patient care and EHR design, which obstructs providers' ability to build the patients' story by fragmenting data interconnections and limiting space for narrative notes. As a result, crucial aspects of the patient's narrative may be lost, particularly emotional and psychosocial elements, impacting the development of a healing relationship. In addition, the ability to build a comprehensive assessment of the patient's clinical trajectory is impeded.10 This “screen-driven” information gathering has been associated with diminished provider clinical reasoning and judgment, leading to potential error and subsequent moral distress.34

Supporting provider empathic concern and engagement with the patient, which is requisite to caring action, will require a redesign of the EHR and development of patient-centered EHR communication skills. Research suggests that these skills are not inherent and should be modeled and taught in both academic curricula and clinical settings. Although best practices have yet to be developed, successful interventions include combinations of lecture, role-playing, use of mnemonics, and videotaped observation of provider-patient interactions.35 Clinical reasoning, or understanding how data are interconnected, is also related to patient-centered EHR communication skills and essential to patient safety. Nurses and informaticists can work with EHR vendors to ensure that this “connectivity” is supported by designing interfaces that present data as chronological interconnections.36

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Justice

Vallor29 describes 2 associated components of the technomoral virtue of justice relevant to a discussion of the EHR, promoting fair and equitable distribution of associated benefits and risks and addressing how the technology may affect the rights, dignity, or welfare of individuals and groups. An example is recognizing and including the social and behavioral determinants of health (SBDOH) in the EHR.

Screening for health-related social/behavioral determinants is essentially different from evaluating traditional health problems for which interventions exist within the health care system. Assessing adverse conditions or situations without the capacity to provide appropriate referral and/or resources is ineffective and, potentially, unethical. At present, few comprehensive, evidence-based models exist that provide linkages to the myriad sectors required to address the needs of diverse populations. Strategies to integrate screening with referrals to community-based resources or programs are required.37

Incorporating technomoral justice while avoiding unintended harm when assessing for and including SBDOH in the EHR requires empathic inquiry skills. This approach is patient-centered, nonjudgmental, and based in motivational interviewing and trauma-informed care. It is intended to promote collaboration and provide support for both patients/families and providers in the interview process. Empathic inquiry endeavors to identify patients' priorities regarding their needs as well as their strengths and assets.38 Screening for SBDOH should also not be limited on the basis of apparent social status, as this may only perpetuate negative stereotypes and assumptions.37

Nurses must be cognizant that underlying data entered for collection and analysis are essential to monitor and identify health outcomes but are also subject to bias. This approach for the use of data may also be referred to as data mining. EHRs have the ability to use machine learning with predictive modeling to accurately predict hospital mortality, readmissions, length of hospital stay, and discharge diagnosis, as well as innovative approaches to reduce negative human processes such as stereotyping and bias.39 Undoubtedly, machine learning through the use of algorithms is more efficient and less time-consuming than a person reviewing a health record in its entirety.39 An understanding of technomoral justice and civility also extends to the use of stigmatizing language in the EHR, which may reflect an implicit or unconscious provider bias. Cato et al40 discuss potential ethical issues associated with identification of individual characteristics in the EHR40 that might be useful for clinical prediction, management, and decision-making, based on predictive analysis of another patient's de-identified data, also known as phenotyping. Terms such as “substance abuser,” rather than “having a substance abuse disorder,” “frequent flyer,” or other disparaging labels, can also result in delayed or differential treatment. When this language is cut and pasted from previous entries, it may perpetuate inaccuracies and preclude an understanding of the patient in his/her present circumstances.41,42 Conversely, suicidal intent can be ambiguous, and therefore mining EHRs for natural language related to suicidal behaviors in pregnant women successfully increased the number of screening cases from 125 to 1423.43 Recognizing and including the SBDOH in the EHR and avoiding the use of derogatory terms is congruent with nursing's mandate to reduce health inequities and respect the patient's dignity.33 Optimizing this feature of the EHR provides the potential for obvious benefit for patient outcomes, but also raises significant risks of harm, especially due to the stigmatization and vulnerability associated with certain health conditions.40

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Potential risks to data integrity

The potential benefits and efficiency in health care associated with data mining and the use of machine algorithms in EHRs must be evaluated with the risks of harm due to stigma and bias. For example, if there is not enough data for certain groups of patients, possibly due to lack of access to the patient portal or low health literacy levels, the machine algorithm is trained on insufficient data and can fail to provide accurate predictions and lead to disparities in care.39 Capturing data such as race, ethnicity, sexual orientation, gender identity, and other social and behavioral information has ethical and moral significance. “Being counted is an acknowledgment of both existence and value. It means that one matters.”44(p16) More inclusive collection of data from EHRs will allow health care professionals and researchers to monitor risk behavior, progress toward elimination of health disparities, and bridge gaps in provider knowledge.

It is of course incumbent on the patient to provide such data and patients have the autonomy to disclose this information. The nurse or other health care professional should discuss the implications of disclosure including what information might be shared with other providers in order to maintain trust in the patient-provider relationship. SBDOH content, however, has not been integrated into most nursing curricula.45 Strategies to enhance provider knowledge and abilities include practicing empathic inquiry skills, use of simulation, and participation in service-learning opportunities.45

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Moral leadership

We have identified that EHR documentation burden and associated negative effects on the patient-provider relationship contribute to provider moral distress and burnout across the health care disciplines, resulting in turnover or leaving the profession.46 An organization's ethical climate has been shown to exacerbate or ameliorate perceptions of moral distress. A punitive climate that results in a culture of silence serves to perpetuate EHR issues and inaccuracies and calls for moral leadership.

Moral leaders can lead others in projects that “require enduring courage ... expansive empathy, extraordinary care, and tolerance for great frustration and conflict because they have ... cultivated these virtues.”29(p153) Several authors have written about the importance of ethical/moral leadership in nursing and describe how it differs from traditional leadership models. Although all contain moral components, ethical leaders prioritize and focus explicitly on ethical issues, obligations, and practice. They develop and maintain an ethical climate in which problems associated with the EHR and other ethical issues are identified, discussed, and decided.47

Developing ethical leadership skills in nursing is a “complex and multifaceted process.”47(p226) Although nursing educational programs may require a basic ethics course or have integrated content throughout the curriculum, the competence necessary for ethical leadership requires additional knowledge and skills. These skills include but are not limited to self-understanding of personal values, knowledge of diverse codes of ethics, principles and theories, and decision-making frameworks. Ethical or moral leadership is also demonstrated not only by what leaders do, their conduct, but also by their character. These nurses develop a range of moral virtues including courage, humility, and trustworthiness through practice and reflection.

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RECOMMENDATIONS ON RECONCEPTUALIZATION OF THE EHR

Education

Although many positive aspects of the EHR have been realized since 2009, the issues identified in this article and in others calls for the integration of ethical competencies beyond those outlined in the TIGER initiative,24 data security, privacy, and ethical use of social media. Effective communication is central to the nurse-patient relationship, cultivation of empathic skills, and subsequent caring actions. To mitigate the potential negative effects of EHR distraction on this relationship, didactic and clinical education should include deliberate instruction and modeling of patient-centered EHR communication skills and behaviors. Several curricular models exist that incorporate lecture with experiential learning and application of a mnemonic summarizing evidence-based best practices for patient-centered EHR use. These practices include “using the triangle of trust” to position the screen where the provider and patient can both see it, when appropriate, and maintaining eye contact as much as possible.48

The diversity of technology and its impact on the nursing discipline and health care continues to increase. While many present and future effects on patient care are and will be positive, challenges persist. To explore the ethical implications of these challenges, educators can teach and model virtue ethics.

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Research

Research in regard to the use of the EHR and the experiences of those providers who must use the EHR on a day-to-day basis is vast. We are beginning to understand the impact of positive as well as negative experiences. For example, the statewide study of Texas nurses and their experience using the EHRs indicated a wide range from advantages experienced in deploying optimum standards of care to disadvantages experienced in breakdown in communication among key health care team members.9 Focus on the provider's experience associated with the 21st Cures Act18 is another example of the impact on providers. In the end, it is the competencies, not only of the providers and the EHR vendors and the EHR implementers, but most importantly it is the competencies of leadership that will matter.

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Organizational accountability

Organizations must not embody a culture of silence, described as collectively exerting minimal efforts in response to significant problems.18 Specifically, it is imperative for nurse leaders, and other hospital executives to listen and learn from the provider's lived experience when using the EHR.31 Interprofessional organizational leaders who decide which software to purchase to support the needs of the facility must consider choosing the EHR design that supports the provider's ability to accurately build the patient's narrative and share this narrative interprofessionally. In the context of the Innovative Nurse Leader model, professional interoperability extends far beyond making systems and technology interoperable. Professional interoperability is the combination of highly developed professional skills and competencies applied effectively to share meaningful information, knowledge, and expertise within and across diverse and often competing disciplines, in working toward innovative health IT solutions to health care challenges.24 Lastly, organizational leaders must recognize widespread burnout and moral distress among providers and provide resources to address and mitigate these barriers to practice.46

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CONCLUSION

In this critique and innovation article of technology versus caring, we challenge the original ideas posed by Petrovskaya et al that the appearance of conflict of the EHR and the caring roles and expectations of the nursing profession be examined solely through a tetralemma concept. We introduced several approaches for nurses, nursing leaders, and other health care professionals working with the EHR. The advancement of the EHR after the passage of the HITECH Act has resulted in the discovery of unintended consequences discussed in a polarity thinking framework, in addition to the cultivation of technomoral wisdom and virtue ethics. While the tetralemma has been proposed as a way to consider the concepts of art and science or theory and practice in nursing,49 it has not been used again in conjunction with the EHR. Polarity thinking, however, is reflected in practice-based use of polarity models specific to the issues of EHR documentation and the associated provider experiences.50 It is important for nurses and other health care providers to consider both the tetralemma approach with the polarity framework when evaluating issues affecting practice including clinical decision support, interoperability, usability, team communication, person-centered care, and risks, benefits, and burdens of documentation and data integrity. Providers and organizations must evaluate all of these issues to strategize and accurately build the patient's narrative within the EHR and mitigate potential negative effects of the EHR on nurses and nursing practice. Given the rapid practice and policy changes related to the EHR, more research and education is critical to advance nurses' role in the technomoral integration of caring technology and the EHR.

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REFERENCES

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3. US Department of Health and Human Services. HITECH act enforcement interim final rule. http://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/. Updated 2012.
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Keywords:

electronic health records; moral distress; polarity thinking; technomoral wisdom; tetralemma

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