Amongst the many initiatives by the Singapore governmenttowards building a Smart Nation, the national electronic health records (NEHR)system was introduced in 2011 in a bid to realize the Ministry of Health’s(MOH) vision of “One patient, one health record” for Singapore. In 2017, theMOH makes the bold move of mandating every healthcare providers in Singapore toupload their medical data (such as key diagnoses, discharge summaries, medicaland drug histories) onto NEHR, placing Singapore as amongst the first countryin the world to adopt such a comprehensive system (Lai, 2017). In such a broadtransition from paper-based to electronic health records (EHR), the unprecedentedaccessibility of patients’ health records to healthcare providers presents apotential for the amplification of any benefits and dangers that might arisefrom it. Arguably, an increased accessibility of healthcare providers to thepertinent medical information of a patient under their care justifies the act,since the improved accessibility could translate into better healthcare for thepatient in question. Medical students’ ability to access such privilegedinformation however falls in a more controversial realm, since the bulk of anybenefits to patients will be realised for future individuals and notnecessarily the patient whom they are eliciting information from for theireducation.

Hence in this paper, we will examine the ethical basis andimplications regarding the ability of medical students to access EHRs. We willalso propose measures through which medical students may access and trackpatients’ records in an ethically appropriate manner. Case-based learning (CBL) in medicine is a well-establishedpedagogical method that involves the studying of clinical, basic and socialsciences in relation to patient cases, allowing for an immediatecontextualization of one’s medical learning to real-life situations (Thistlethwaite, et al., 2012). The access to healthrecords presents the most direct means of obtaining resources for such a learning- providing doctor’s clinical notes, lab and imaging results, management plans– thereby empowering students to audit their diagnostic impressions andmanagement (Adibe & Jain, 2010).

At present, all 6major healthcare systems of Singapore – NHG, AHS, Singhealth, EHA, NUHS andJurongHealth – have within their data protection statement clauses that allowsfor the collection of patient data to “ensure that staff, volunteers, students(including medical students, trainees or other staff) are properly trained toprovide medical services or execute their functions in the context ofhealthcare operations generally” (Singhealth, 2017). These statements were set up inresponse to the Personal Data Protection Act (PDPA) that was put into place asa baseline law to “ensure a common standard of protection for individuals’personal data across organisations in Singapore” (Singhealth, 2017). As a result, these statements comprisesof explicit clauses describing the rights of individuals to withhold or withdrawconsent to the collection, use or disclosure of their personal data, therebyhighlighting the tension between data collection for education and patient’sprivacy. Similar dichotomies are found embedded in medical guidelines of othercountries such as the American (American Medical Association, 2016) and Canadian MedicalAssociations (Canadian Medical Association, 2004).

Argumentsfor access to NEHRProponents of ability to access clinical case notes cites 1) itseffectiveness as a training tool that is proven by research as well as it beingrecognised as an important component since the beginning of modern medicaleducation. 2) They also cite the fulfilment of one of the four pillars ofmedical ethics – beneficence – as reason for its necessity.Since the first adoption of problem-based learning (or CBL)by McMaster University Faculty of Health Sciences in 1972 (Barrows, 1996), a flurry of research and surveys havebeen done to gauge its effectiveness in training better physicians. Variouspapers have shown its effectiveness in objectively improving students’ academicperformances as well as subjectively through how well-received it is by bothstudents and tutors alike who have undergone it (Thistlethwaite, et al., 2012); citing reasons suchas how it is able to engage, rouse curiosity and solidify their understandingof the subject in logical thinking, clinical reasoning and diagnosticinterpretations (Nair, Shah, Seth, Pandit, & Shah, 2013).

The value of apatient-based learning is also recognised since the beginning of modern medicaleducation, citing Sir William Osler’s famous quote of “He who studies medicinewithout books sails an uncharted sea, but he who studies medicine withoutpatients does not go to sea at all” (Prober & Heath, 2012).In addition, on the premise of CBL’s ability to improve one’smedical training and hence providing long term benefit to one’s future patientsand society as a whole, one can argue that it is even morally obligated for anindividual to engage in CBL in fulfilment of beneficence, one of the 4 pillarsof medical ethics (Brisson, Neely, Tyler, & Barnard, 2015). Failing which,one’s ‘inadequate training’ may potentially endanger one’s patients and causeone to face negligence charges.Argumentsagainst access of NEHROpponents argue on the basis that such assess 1) contravenesan individual’s autonomy, 2) may serve to distract medical students frompersonally examining the patients and 3) bypass the need for students tosynthesize clinical information.Autonomy refers to the respect for patient’s right toself-determination and it is in part expressed through the law of privacy.

Richard Rognehaugh defines privacy as “the right of individuals to keepinformation about themselves from being disclosed to others, the claim ofindividuals to be let alone, from surveillance or interference from otherindividuals, organizations or the government” (Rognehaugh, 1999). In other words, the right of individualsto decide to whom and what information about themselves is shared. However, dueto the nature of medical information (which is often full of jargons and collaborativewhereby removal of any component may make interpretation of the remaining data difficult),it may be prohibitively difficult for a laymen to customise his release ofpersonal information. Hence patients are often presented with an’all-or-nothing’ option – to release all pertinent medical and socialinformation about themselves or to refrain from it completely, the latter ofwhich may result in the healthcare team terminating treatment for the patientto avoid undue risk (Singhealth, 2017). Likewise, it is logistically difficultto customise what patient information medical students have access to,therefore often is the case whereby Medical students are able to access most ofthe information about the patient the healthcare team has access to as well.The danger in granting accessibility to medical students (and indeed to anyonewho has access to the information) is that the lack of confidentiality mayresult in the disclosure of personally identifiable health information to aninsurer, employer or family member which may in turn engender embarrassment,discrimination and stigma. 2013 was one such instance when a NUS medicalstudent tweeted about a patient’s pregnancy and abortion history (Teng, 2013).

Such breaches mayin turn precipitate “patient’s anxiety, loss of privacy and perhaps areluctance to seek care” (Rothstein, 2010). Hence, one could argue that with suchrisks involved accompanied by minimal benefits to the patient in question,medical students’ access to clinical case notes should be disallowed.   Prior to the era of EHRs, students are largely dependent on cumbersomepaper notes to read and understand about a patient’s case, hence elicitinginformation from the patient himself may serve as a more efficient use of time.The launch of EHR enables rapid up to date access to patient’s data, therebypotentially reducing the need to personally examine the patient. Peled andSagher observed that such a change have brought about a transformation of thearchitecture of the patient care setting – from teacher and student examiningdocuments and engaging one another, to rows of physicians and students liningthe walls staring into computer screens (Peled, Sagher, Morrow, & Dobbie, 2009); or what iscolloquially termed “paper rounds” where rounds are conducted around thecomputer rather than physically with the patients in the wards.

Such a changeif indeed discourages students from physically engaging in a medical interviewwith the patient, would severely incapacitate one’s medical education,especially in the “art” side of medicine which Lichstein describes as the”interpersonal skills needed to establish rapport with the patient andfacilitate communication…something magical or mysterious…that cannot bedescribed or taught” (Lichstein, 1990). This is not to mention the inabilityto carry out physical examination, an indispensable tool in medicine.Additionally, the access to clinical notes may bypassstudents’ need to synthesize clinical information (Peled, Sagher, Morrow, & Dobbie, 2009). Prior to EHRs,students have to quickly learn how to distil medical information and presentthem in a coherent and succinct manner. With the easy access to clinical casenotes and all its summarised findings done by senior clinicians, there may beless incentives for students to think critically and summarise the findingsgathered.

This can be done by simply imitating what has already be summarisedin the system, thereby again impeding one’s medical education. As seen above, there is evidently a tension between medicaleducation and patient privacy with compelling arguments both for and againstmedical students’ access to patient information. As described, NEHR presentsitself as a powerful educational tool with wide benefits both for physiciansand students.

If usage is unregulated and applied unethically however, it haspotential for far reaching consequences. The effectiveness of this tool as ameans of education is only as good as its user. Hence there is a critical needto properly regulate its usage to maximize outcomes and mitigate its harm. Herewe will examine several ways how this can be done.

Currentand additional proposed measuresTo address the issue on respect for patient’s autonomy, a topdown rule-driven and bottom up education on individual professionalism approachcan be adopted. Further sub-dividing the rule-driven approach, legal andtechnological aspects can be touched upon to enforce it. ‘Legally’, medical students are oath-bound the moment theyare sworn in to the medical profession – “I solemnly pledge to…respect thesecrets which are confided in me” (WMA, 2017)– as well as their signing of confidentiality agreements before startingclinical training in hospitals.

Professional misconduct of medical studentshence disposes them to facing disciplinary actions such as suspension or evenexpulsion. This is withholding the rights of the victim (patient) to pursue civilproceedings against the offender (Fong, 2001). Technologically, hospitaladministrators have the ability to review individuals’ access of electronic healthrecords.

Hence enforcement of proper usage of the NEHR would generally not be anissue. Additional technological measures can also be put into place to regulatedegree of information available to authorized users based on pre-establishedrole-based privileges (Ozair, Jamshed, Sharma, & Aggarwal, 2015). Access for medicalstudents could be altered such that sensitive medical information notimmediately relevant to their educational objective such as where a patientstays, the patient’s income etc. are restricted. It is however often prohibitively difficult to determine theexact nature of information to censure or allow and what is exactly relevant toa medical student’s education. It is therefore more critical to properlyeducate medical students on medical ethics and proper stewardship over theprivileged information they are afforded by patients, whom have generouslyshared their private data yet received minimal or even non-existent clinical contributionfrom the beneficiaries (students).

A simple act of asking for the patient’spermission before accessing their records as a result of such an understandinggoes a long way to affirm patient’s autonomy. Having a portal through whichsuch permissions obtained can be documented would serve to affirm its authenticity.On top of this, students should only do so with a genuine educational intentand restrict themselves from accessing information beyond those essential foreducation (Brisson, Neely, Tyler, & Barnard, 2015). The rule ofconfidentiality and respect for patient’s autonomy must be strictly upheld inorder to instil confidence in patients seeking treatment.To address the issue of NEHR eroding the fundamentals of goodmedical education, strong emphasis should be placed on teaching the hallmarksof being a good clinician as well as the necessary steps to achieve that.

Forinstance, using the NEHR as a means to audit diagnostic impressions andmanagement rather than as a quick means to obtain the ‘answers’ would enableone to take charge of one’s own education – to independently undertake theproper rites of a medical interview and then audit oneself based off therecords without having to constantly turn to a senior clinician forverification. As described by Mcloughlin, one of the characteristic of a failingmedical student is one whom “rarely thinks further ahead than graduation…theyare overly focused on being an acceptable medical student” (Mcloughlin, 2009). A medical student whom only seeksshortcuts is not able to move beyond the identity of a student when shortcutsare no longer available. NEHR is a facilitative tool to assist in clinicalreasoning, not a replacement.

Misunderstanding this would undermine itspowerful function to augment CBL and instead ironically brings one back to apre-CBL era. With the increasing adoption of EHRs, especially with therecent mandating of NEHR by the Singapore government, it is expected that most,if not all medical students would have at one point access to such electronicrecords. Although NEHR offers significant advantages in training medicalstudents, it is fraught with its own risks if used inappropriately.

Afterexamining both sides of the arguments, we can conclude that access to therecords is indispensable for medical education but not without its definedlimits – guidelines should clearly defined the appropriate obtainment and usageof such privileged information and be enforced; as well as educating one’sconduct and stewardship over it. Only then can we justify the progress ofmedical education in line with a patient-centric healthcare system.  


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