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Is EHR Usability Design Ethical for Behavioral Healthcare?

According to a recent JAMA article, EHR usability design alerting providers of ED "frequent flyers," or behavioral health patients, may be unethical.

By Sara Heath

- While EHR usability design is often centered on producing quality care outcomes, they may not be ideal for integrating the tools into behavioral healthcare. In many cases, EHR design may not be ethical for behavioral healthcare.


In a recent article published in the Journal of the American Medical Association, healthcare experts discuss the use of EHR flagging tools that utilize icons to categorize certain patients. The op-ed contends that these flags may inhibit patient safety and potentially breach healthcare ethics.

According to authors Michelle Joy, MD, Timothy Clement, MPH, and Dominic Sisti, PhD, some emergency department EHRs have system designs that flag patients who are “frequent flyers” to the ED. These patients visit the emergency department often and are typically those presenting symptoms of mental illness or substance abuse.

While some EDs maintain lists of these patients, others employ EHR flags that feature a small airplane icon beside the patient name to mark them as a regular utilizer. These icons take on a different color depending upon the degree to which the patient over utilizes the ED.

According to Joy, Clement, and Sisti, these EHR flags are problematic because they promote mental illness and substance abuse stigma and potential provider bias. Both of these may pose a threat to care delivery and patient safety.

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“The icon offers an example of how potentially harmful biases may be built into and reinforced by well-intentioned but ill-conceived information technologies, such as those deployed widely across all sectors of health care, and particularly in psychiatric treatment settings where clinical interactions are often more interpersonally sensitive,” the trio wrote.

These EHR alert symbols are problematic because they perpetuate the use of stigmatizing language. This may potentially reinforce stereotypes clinicians and other hospital workers may unconsciously have about patients with mental illness or substance abuse disorders.

The authors explained that encouraging this kind of stigma, even if it is not ill-intentioned, may lead to diagnostic overshadowing.

Many over utilizers may present to the ED because they have a physical condition alongside their mental health condition. However, in marking these patients as over utilizers using an icon that potentially promotes a subconscious stigma, these patients may not receive the physical care that they need.

“Seeing the high utilizer icon at the time of the patient encounter may increase the likelihood that a clinician will possibly fail to recognize medical problems,” said Joy, Clement, and Sisti.

“The notion that the patient is a ‘frequent flyer’ may interfere with the assessment of legitimate somatic symptoms and may cause the clinician to withhold or delay needed tests and procedures, which could lead to serious negative outcomes.”

The authors maintained that these patient safety and ethical issues are likely not intentional.

“In the case of the airplane icon,” the authors wrote, “it seems unlikely that those who developed it and those who agreed to deploy it did so without direct guidance and endorsement from clinicians whose professional vernacular may include the term ‘frequent flyers.’”

Likewise, the authors said that these ethical questions should not stop ED physicians from collecting patient histories in an efficient manner.

“Central to taking a patient’s history is learning how often and for what reasons the patient frequently presents in the emergency department or other health care settings,” the authors explained.

However, in order to make the best use of that information, providers need to better contextualize it and understand the motivators behind patient ED use. Reducing that context down to an EHR alert icon, the authors argue, does not effectively aid patient care.

To improve these potential issues, the authors suggest EHR developers turn to all stakeholders, including patients, physicians, social scientists, and ethicists to ensure that they approach healthcare in an ethically sound manner.

By taking into account the needs and suggestions from multiple healthcare and sociological experts, EHR developers can help create tools that are best designed to improve health for all patient populations. These design improvements could ultimately improve patient safety.

“At the very least, health information technologies should do no harm,” the authors concluded. “A system that confusingly displays acronyms or medication names would be considered unsafe. Likewise, systems that use stigmatizing iconography should also be unacceptable.”

The question of behavioral health and health IT has risen to the forefront. Earlier this year, two researchers from the University of Vermont College of Medicine explained that EHRs are not mature enough to support the needs of behavioral health clinicians. Many of the issues plaguing primary care providers are affecting behavioral health clinicians more strongly:

EHRs are still in their youth (or adolescence), and have not yet grown into the hopes that many have for them. Templates for documentation, ease of use, interoperability, ability to extract data fields, use as part of care algorithms, and responding to the multiple needs for functionality for a broad range of users are among the current issues being considered. Applications for behavioral care within EHRs suffer the same and perhaps greater frustrations of all EHR users: how to use the available technology to meet their needs. These frustrations are often administrative rather than technical issues. The priority and pressure for developing integrated behavioral care systems is just emerging.

Another study states that most EHRs are missing a vast amount of behavioral health data.

Nearly 30 percent of patients with bipolar disorder or depression had their behavioral health diagnoses missing from their EHRs, the study found. These gaps in care may have serious implications for future physician EHR use.

“Above all, individual providers and health system leaders need to be fully cognizant of the information gaps and disconnects that lie behind the screen,” the study authors explained. “Feature that are intended to improve care and protect patients from harm may be inadequate in typical fragmented health systems, offering false comfort.”

As the industry continues to shift to patient-centered healthcare supported by EHRs, it will be important for providers and EHR developers to determine the best practices for these tools in the behavioral health setting.

Between honoring patients and their dignity and ensuring that data collection is useful, these tools will need to be structured in a way that providers can produce optimal care outcomes.

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