The use of electronic health records (EHR) is increasingly becoming inevitable in the health care sector in both developed and developing countries globally. In the USA, for instance, a significant number of hospitals or healthcare providers are using EHR due to its many benefits, such as reducing paperwork and eliminate the wrong prescriptions, resulting in improved care service and patient outcomes. Consequently, one of the main American Nurses Association’s (ANA) policy statements is EHR. ANA makes it clear in the statement that it supports the use of EHR because it is beneficial to the healthcare sector, as well as nursing practices. According to ANA, EHR can be used to improve the documentation and storage of patient health data and information. Nonetheless, ANA is concerned that EHR can lead to many ethical problems, such as the violation of the principle of privacy, confidentiality, literacy, and security (ANA, 2009) . At the same time, the usability of EHR can result in an ethical dilemma for nurses, especially when they are not adequately integrated and interoperable, including when the accessibility of patient data is a challenge. Therefore, EHR poses ethical dilemmas for both healthcare providers and patients, including nurses.
Bioethical Principles
Bioethical principles generally refer to four basic principles that guide healthcare practices and professionals. The principles include autonomy, justice, beneficence, and privacy and confidentiality. A medical or health practice is believed to be ethical if it adheres to the four principles. At the same time, any medical technology like EHR is expected to comply with the bioethical principles ( Ozair et al., 2015) . Therefore, it is essential to determine whether ANA’s policy statement on EHR meets the current ethical standard of care.
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The primary concerns associated with EHR relate to patient privacy and confidentiality. The principle of patient privacy and confidentiality ensures that patients' health information is not only kept private while maintaining its confidentiality. Patients are always entitled to their privacy and confidentiality rights. However, EHR has been associated with many confidentiality and privacy breaches. For instance, Howard University Hospital in Washington, D.C, suffered one of the worst patient privacy and confidentiality breaches when a laptop containing patient data was stolen. It is estimated that about 34,503 patients were affected by the incident ( Ozair et al., 2015) . Therefore, even though ANA fully supports the implementation of EHR in hospitals, it maintains that it must safeguard patients’ privacy and confidentiality in its policy statement that focuses on technology. Specifically, ANA states that the principle of privacy and confidentiality should never be compromised when hospitals and health professionals are using the technology (ANA, 2009) . At the same time, to avoid the violation of the ethical principle, ANA emphasizes that data and information must be accurately and efficiently gathered, recorded, stored, and utilized when hospitals and implementing EHR. Therefore, ANA is determined to ensure that EHR meets the principle of privacy and confidentiality, especially that of patients.
However, EHR is causing one of the greatest ethical dilemmas for health professionals like nurses. Specifically, the determination to maintain patients’ privacy and confidentiality can conflict with the beneficence, primarily when EHR is integrated to allow various health professionals to use it to improve the quality of healthcare services. EHR can completely prevent some people from accessing patient health information when security interventions like passwords and encryptions are used ( Ozair et al., 2015) . As a result, some health professionals can find it challenging to access patient information to provide quality and timely care services, majorly during emergencies. The ethical principle of beneficence requires nurses or any other health professional to do good for the patient, which may only be possible if relevant data and information are accessible and readily available.
As a result, to ensure that EHR meets the ethical principle of beneficence, ANA is using the policy to make sure that the system is integrated and interoperable. The policy states explicitly that EHR should be designed and implemented in such a way that they enhance effective interprofessional and patient communications, as well and effective decision-making process whenever patients need healthcare services. Even though EHR should be designed to limit the accessibility of patient care information, it should be flexible enough to allow the accessibility of critical information during emergencies (ANA, 2009) . The system should not hinder the work of healthcare professionals in any way, while at the same time, it should not increase patient morbidity or mortality. For instance, nurses who work in emergency departments should be allowed to access patient information to improve patient outcomes quickly.
Besides, EHR should promote the ethical principle of justice, which is mainly defined as fairness to all parties involved in an activity or process. According to the principle of justice, all relevant stakeholders in the healthcare sector should be allowed all people to access healthcare services while considering the interests of other people. Therefore, apart from improving the accessibility of patient health information, the planning and implementation of EHR should involve all parties, including nurses and patients. The planning and implementation of EHR should not just be left for technical or information technology (I.T.) experts. Nurses should also be involved in its implementation, mainly based on the ethical principle of justice (ANA, 2009) . ANA’s policy statement states that nurses should actively be involved in the implementation of EHR systems. Also, to promote justice, EHR should be standardized and interoperable, which is essential in improving patient outcomes.
Besides, nurses will not get justice if the design of EHR is not based on relevant terminologies that support nursing practice. Terminologies used in the system should be understandable and familiar with a significant number of nurses (ANA, 2009) . Autonomy is one of the major ethical requirements in nursing. Based on the principle of autonomy, people should be allowed to make their own choices or decision without any form of interference. Therefore, EHR should promote not only the autonomy of patients but also nurses. Nurses' autonomy can only be promoted when the system involves the use of appropriate terminologies while at the same time, it is user-friendly (ANA, 2009) . As a result, ANA policy is determined to ensure that EHR uses terminologies that support the nursing practice.
Legislative Influence
Patient privacy, confidentiality, and safety are some of the issues that concern any state or local government. Many lawmakers are determined to protect patient privacy and confidentiality. In Pennsylvania, for instance, lawmakers in the state are always cautious whenever they are dealing with health-related bills or issues. They are not likely to pass any bill that compromises patient privacy and confidentiality. At the same time, the Pennsylvania Patient Safety Authority is concerned about the safety and effectiveness of EHR. Therefore, lawmakers in the state are likely to support any relevant position statement that addresses that promote patient privacy, confidentiality, and safety ( Ozair et al., 2015) . They will ensure that the implementation of EHR in various hospitals in the state is not only legal but also ethical.
Nurses can use many strategies to influence change at the state and federal legislative levels. Importantly, they should use their knowledge and expertise to initiate relevant policy proposals that promote nursing practice and activities to improve the quality of care. Nurses should use policy proposals to advocate for change ( Abood, 2017) . Besides, nurses should actively be involved in the legislative process by conducting policy workshops and offer policy internship on relevant nursing-related bills. Also, ANA has lobbied for lawmakers to enact relevant laws or formulate policies that protect patient privacy and confidentiality, especially concerning the use of EHR. Specifically, ANA has been working closely with legislators to support legislation and policies that aimed at protecting patient health information. Nonetheless, ANA should actively be involved in the legislative process.
Conclusion
The position statement on EHR is important because it touches or affects almost all bioethical principles, which affects nursing practices. Nurses are required to uphold patient privacy and confidentiality. However, this is only important when EHR systems are properly designed and implemented. Nurses are likely to be ignored in the planning, designing, and execution of EHR, leading to poor nursing care or ineffective nursing practice. Thus, to ensure that the policy continues to support ethical nursing practices, nurses should actively be involved in the planning, designing, and implementation of EHR. Involving nurses in the process is important because it ensures that EHR is effectively integrated into the nursing practice, and it enhances interoperability in a healthcare entity. Although EHR is beneficial, it should promote ethical practices in the healthcare sector.
References
Abood, S. (2017). Influencing health care in the legislative arena. OJIN: The Online Journal of Issues in Nursing , 12 (1).
ANA. (2009). ANA Position Statement: Electronic Health Record . Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position- statements/id/electronic-health-record/
Ozair, F. F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical issues in electronic health records: A general overview. Perspectives in Clinical Research , 6 (2).
