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Review Article
Fouzia F. Ozair,
Nayer Jamshed1,
Amit Sharma2,
Praveen Aggarwal1
Ethical issues in electronic health
records: A general overview
Department of Health Services,
Jawahar Lal Nehru University,
Department of Emergency Medicine,
All India Institute of Medical Sciences,
Department of Forensic Medicine,
Hamdard Institute of Medical Sciences
and Research, New Delhi, India
Address for correspondence:
Dr. Nayer Jamshed,
Department of Emergency Medicine,
All India Institute of Medical
Sciences, Aurobindo Marg,
New Delhi ‑ 110 029, India.
E‑mail: jamshednayer@gmail.com
Ab stract
Electronic health record (EHR) is increasingly being implemented in many developing countries.
It is the need of the hour because it improves the quality of health care and is also cost‑effective.
Technologies can introduce some hazards hence safety of information in the system is a real
challenge. Recent news of security breaches has put a question mark on this system. Despite its
increased usefulness, and increasing enthusiasm in its adoption, not much attention is being paid
to the ethical issues that might arise. Securing EHR with an encrypted password is a probable
option. The purpose of this article is to discuss the various ethical issues arising in the use of
the EHRs and their possible solutions.
Key words: Confidentiality, electronic health record, paper record, security breaches
An electronic health record (EHR) is a record of a
patient’s medical details (including history, physical
examination, investigations and treatment) in digital
format. Physicians and hospitals are implementing EHRs
because they offer several advantages over paper records.
They increase access to health care, improve the quality
of care and decrease costs. However, ethical issues related
to EHRs confront health personnel. When patient’s
health data are shared or linked without the patients’
knowledge, autonomy is jeopardized. The patient may
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conceal information due to lack of confidence in the
security of the system having their data. As a consequence,
their treatment may be compromised. There is the risk of
revelation of thousands of patients’ health data through
mistakes or theft. Leaders, health personnel and policy
makers should discuss the ethical implications of EHRs
and formulate policies in this regard. The electronic
medical record (EMR) is the tool that promises to provide
the platform from which new functionality and new
services can be provided for patients.
A medical record in the past was information documented
on paper for research, clinical, administrative and financial
purposes. Its major drawback was in terms of accessibility,
and it was available to one user at a time. Its completion
was delayed anywhere from 1 to 6 months or more because
it was updated manually.[1]
Perspectives in Clinical Research | April-June 2015 | Vol 6 | Issue 2
Ozair, et al.: Ethical issues in electronic health records
The purpose of documentation through electronic media
remains the same even today that is to support patient
care. EHRs have several advantages over paper records.
Production of legible records reduces many problems of
wrong prescriptions, doses and procedure.[2] Moreover
adverse drug reactions can be reduced substantially when
the EHRs are connected to drug banks and pharmacies.
This can be done by not permitting prescription and order
for drugs for which a known adverse reaction is known
for a certain patient.[2] Easy accessibility from anywhere at
any given time is also beneficial.[3] They require less storage
space and can be stored indefinitely. They reduce the
number of lost records, help research activities, allow for
a complete set of backup records at low cost, speed data
transfer and are cost‑effective.[4,5] Hence, EHRs have been
shown to improve patient compliance, facilitate quality
assurance and reduce medical errors.[6]
The office of the National Coordinator for Health
Information Technology (IT) refers to the health record
as “not just a collection of data that you are guarding, it is
life.”[7] The patient owns the information in the record. The
physician and the organization is the owner of the physical
medical record.[8] There are four major ethical priorities
for EHRS: Privacy and confidentiality, security breaches,
system implementation, and data inaccuracies.
Justice Samuel Dennis Warren and Justice Louis Brandeis
define privacy as the right “to be let alone.”[9] The other
definition given by Richard Rognehaugh is as the right
of an individual to keep information about themselves
from being disclosed to others; the claim of individuals
to be let alone, from surveillance or interference from
other individuals, organizations or the government.[10]
Information of a patient should be released to others only
with the patient’s permission or allowed by law. When a
patient is unable to do so because of age, mental incapacity
the decisions about information sharing should be made
by the legal representative or legal guardian of the patient.
Information shared as a result of clinical interaction
is considered confidential and must be protected. [11]
Information from which the identity of the patient cannot
be ascertained for example, the number of patients with
breast carcinoma in a government hospital, is not in this
Health care institutions, insurance companies and others
will require access to the data if EHRs are to function as
designed. The key to preserving confidentiality is to allow
only authorized individuals to have access to information.
This begins with authorizing users. The user’s access
is based on preestablished role‑based privileges. The
Perspectives in Clinical Research | April-June 2015 | Vol 6 | Issue 2
administrator identifies the user, determines the level
of information to be shared and assigns usernames and
passwords. The user should be aware that they will be
accountable for the use and misuse of the information
they view. They have access to the information they need
to carry out their responsibilities. Hence assigning user
privileges is a major aspect of medical record security.[13]
Although controlling access to health information
is important, but is not sufficient for protecting the
confidentiality. Additional security steps such as strong
privacy and security policies are essential to secure patient’s
Security breaches threaten patient privacy when
confidential health information is made available to
others without the individual’s consent or authorization.
Two recent incidents at Howard University Hospital,
Washington showed that inadequate data security can
affect a large number of people. On May 14, 2013,
federal prosecutors charged one of the hospital’s medical
technicians with violating the Health Insurance Portability
and Accountability Act (HIPAA). Prosecutors said that
over a 17‑month period, Laurie Napper used her position
at the hospital to gain access to patients’ names, addresses
and Medicare numbers in order to sell their information.
A plea hearing had been set for June 12, 2013 in which
she was found guilty and sentenced for 6 months in a
half‑way house and fined $2,100. A few weeks earlier, the
same hospital informed more than 34,000 patients that
their medical data had been compromised. A contractor
working with the hospital had downloaded the patient’s
files onto a personal laptop, which was stolen from his
car. The data were password protected, but unencrypted,
which means anyone who guessed the password could
have accessed the patient files without a randomly
generated key. By encryption, we mean encoding of
information in such a way that only authorized parties
can read it. It is usually done with the help of encryption
key, which specifies that how the information should be
decoded. According to a hospital press release, those files
included names, addresses, and Social Security numbers
and in a few cases, “diagnosis related information”.
Recently a hospital chain named Prime Health care
Services Inc. has agreed to pay $275,000 to settle a federal
investigation into alleged violation of patient privacy.
Keeping records secure is a challenge that doctors, public
health officials and federal regulators are just beginning
to understand. Cloud storage, password protection, and
encryption are all measures health care providers can take
to make portable EHRs more secure. A survey conducted
found that 73% of physicians text other physicians
Ozair, et al.: Ethical issues in electronic health records
about work.[14] Mobile devices are for individual use and
are not designed for centralized management by an IT
Department.[15] Mobile devices can easily be misplaced,
damaged, or stolen. Emphasis must be laid on encrypting
mobile devices that are used to transmit confidential
information. Portable EHRs can be made more secure by
using cloud storage, password protection, and encryption.
Usage of two factor authentication system with security
tokens and password are helpful in securing EHRs.
Security measures such as firewalls, antivirus software, and
intrusion detection software must be included to protect
data integrity. Specific policies and procedures serve to
maintain patient privacy and confidentiality. For example,
employees must not share their ID with anyone, always log
off when leaving a terminal and use their own ID to access
patient digital records. A security officer must be designated
by the organization to work with a team of health IT experts.
Routine random audits should be conducted on a regular
basis to ensure compliance with hospital policy. All system
activity can be tracked by audit trails. This includes detailed
listings of content, duration and the user; generating
date and time for entries and logs of all modifications to
EHRs.[16] When there is inappropriate access to a medical
record, the system can yield information about the name
of the individual gaining access; the time, date, screens
accessed and the duration of the review. This information
is useful when determining whether the access is the result
of an error or an intentional, unauthorized view. The
HIPAA Security Rule requires organizations to conduct
audit trails, requiring that they document information
systems activity[17] and have the hardware, software, and
procedures to record and examine activity in systems that
contain health information.[18]
Outside vendors create special privacy issues. Employee‑only
access to the EMR requires any external vendor to access
and navigate the record under the authorization and
oversight of an employee.
Health care organizations encounter major challenges
in the course of EHR implementation these challenges
result in wasted resources, frustrated providers, loss of
confidence by patients and patient safety issues. The
development, implementation, and maintenance of EHRs
requires adequate funds and the involvement of many
individuals, including clinicians, information technologists,
educators, and consultants.[19]
Hospitals and health care institutions are making
improvements without significant clinician engagements.
Many EHR implementation projects fail because they
underestimate the importance of one or more clinician
to serve as opinion leaders for providers in the clinic.
Thus, clinician must guide colleagues in understanding their
roles in the implementation and enlisting their involvement
in tasks as EHR selection, workflow design, and quality
Clinical personnel often have little knowledge of the
clinic’s workflow and the roles others play in care delivery.
This blind spot results in inadequate planning for successful
implementation. Without identifying a standardized
best practice method to do the work, every user is left
to struggle. Clinics should map and standardize their
workflows before EHR selection.
When any two systems are integrated, an interface is
created. By the user interface, we mean an interface between
the user and the computer system. These interfaces are
critical to the overall success of the implementation
process. Interface issues are the greatest system risk
because these failures can be invisible initially. Lack of
systemic consideration of users and tasks often results
in poor user interface. Poorly designed user interface
account for unintended adverse consequence leading
to decreased time efficiency, poor quality of care and
increased threat to patient safety. Improperly designed
user interface fail to deliver the much needed quality of
care, which lead to user dissatisfaction. The faulty user
interface issue, which was small earlier on, increases over
a period of time that leads to abandonment of EHR.
Maintenance and testing of these interfaces on a routine
basis is essential in controlling this major risk. Practice
disruption during EHR implementation can negatively
impact the quality of care or endanger patient safety
along with financial loss.[21]
Integrity assures that the data is accurate and has not
been changed. EHRs serve as a way to improve the
patient’s safety by reducing healthcare errors, reduce
health disparities and improve the health of the public.[22]
However, concerns have been raised about the accuracy
and reliability of data entered into the electronic record.
Inaccurate representation of the patient’s current condition
and treatment occurs due to improper use of options such
as “cut and paste”. This practice is unacceptable because
it increases the risk for patients and liability for clinicians
and organizations.[16,23] Another feature that can cause a
problem in the data integrity is the drop down menu and
disposition of relevant information in the trash. Such
menus limit the choices available to the clinician who in a
Perspectives in Clinical Research | April-June 2015 | Vol 6 | Issue 2
Ozair, et al.: Ethical issues in electronic health records
hurry may choose the wrong one leading to major errors.
Clinicians and vendors have been working to resolve
software problems to make EHRs both user‑friendly and
Loss or destruction of data occurs during data transfer;
this raises concerns about the accuracy of the data base
as patient care decisions are based on them.[24] A growing
problem is of medical identity theft. This results in
the input of inaccurate information into the record of
the victim. The person’s insurance company is billed
for medical services not provided to the actual policy
holder and the patient’s future treatment is guided by
misinformation that neither the patient nor provider
immediately recognize.
India is providing quality health care of international
standards at a relatively low cost and has attracted the
patients from across the globe. India is now one of
the favorite destinations for the health care services.
Considering rapid pace of growth of health care sector in
India, Government of India in April 2013, came out with
definitive guidelines for EHR standards in India. Guidelines
were based on the recommendations made by EMR
standards committee, which was constituted by an order of
Ministry of Health and Family Welfare. It was coordinated
by Federation of Indian Chambers of Commerce and
Industry on its behalf. The guidelines recommend set of
standards to be followed by different health care service
providers in India and hence that medical data becomes
portable and easily transferable.[25] India having a population
of 1.27 billion people with only 160 million internet users
maintenance of EHR is a daunting task, but with the
interest and support of the Government of India in its
implementation, it will a success soon.
Regardless of one’s role, everyone will need the assistance
of the computer. Creating a useful EHR system will require
the expertise of physicians, technology professionals,
ethicists, administrative personnel, and patients. Although
EMRs offer many significant benefits, the future of health
care demands that their risks be recognized and properly
managed or overcome. Multiple strategies are available to
reduce risks and overcome barriers in the implementation
of digital health records. Leadership, teamwork, flexibility,
and adaptability are keys to finding solutions. EMRs
capacities must be maximized in order to enhance improve
the quality, safety, efficiency, and effectiveness of health
care and health care delivery systems.
Perspectives in Clinical Research | April-June 2015 | Vol 6 | Issue 2
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How to cite this article: Ozair FF, Jamshed N, Sharma A, Aggarwal P.
Ethical issues in electronic health records: A general overview. Perspect
Clin Res 2015;6:73-6.
Source of Support: Nil. Conflict of Interest: None declared.

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