Amongst the many initiatives by the Singapore government
towards 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, the
MOH makes the bold move of mandating every healthcare providers in Singapore to
upload their medical data (such as key diagnoses, discharge summaries, medical
and drug histories) onto NEHR, placing Singapore as amongst the first country
in the world to adopt such a comprehensive system (Lai, 2017). In such a broad
transition from paper-based to electronic health records (EHR), the unprecedented
accessibility of patients’ health records to healthcare providers presents a
potential for the amplification of any benefits and dangers that might arise
from it. Arguably, an increased accessibility of healthcare providers to the
pertinent medical information of a patient under their care justifies the act,
since the improved accessibility could translate into better healthcare for the
patient in question. Medical students’ ability to access such privileged
information however falls in a more controversial realm, since the bulk of any
benefits to patients will be realised for future individuals and not
necessarily the patient whom they are eliciting information from for their
education. Hence in this paper, we will examine the ethical basis and
implications regarding the ability of medical students to access EHRs. We will
also propose measures through which medical students may access and track
patients’ records in an ethically appropriate manner.

Case-based learning (CBL) in medicine is a well-established
pedagogical method that involves the studying of clinical, basic and social
sciences in relation to patient cases, allowing for an immediate
contextualization of one’s medical learning to real-life situations (Thistlethwaite, et al., 2012). The access to health
records 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 and
management (Adibe & Jain, 2010). At present, all 6
major healthcare systems of Singapore – NHG, AHS, Singhealth, EHA, NUHS and
JurongHealth – have within their data protection statement clauses that allows
for the collection of patient data to “ensure that staff, volunteers, students
(including medical students, trainees or other staff) are properly trained to
provide medical services or execute their functions in the context of
healthcare operations generally” (Singhealth, 2017). These statements were set up in
response to the Personal Data Protection Act (PDPA) that was put into place as
a baseline law to “ensure a common standard of protection for individuals’
personal data across organisations in Singapore” (Singhealth, 2017). As a result, these statements comprises
of explicit clauses describing the rights of individuals to withhold or withdraw
consent to the collection, use or disclosure of their personal data, thereby
highlighting the tension between data collection for education and patient’s
privacy. Similar dichotomies are found embedded in medical guidelines of other
countries such as the American (American Medical Association, 2016) and Canadian Medical
Associations (Canadian Medical Association, 2004).

for access to NEHR

Proponents of ability to access clinical case notes cites 1) its
effectiveness as a training tool that is proven by research as well as it being
recognised as an important component since the beginning of modern medical
education. 2) They also cite the fulfilment of one of the four pillars of
medical 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 have
been done to gauge its effectiveness in training better physicians. Various
papers have shown its effectiveness in objectively improving students’ academic
performances as well as subjectively through how well-received it is by both
students and tutors alike who have undergone it (Thistlethwaite, et al., 2012); citing reasons such
as how it is able to engage, rouse curiosity and solidify their understanding
of the subject in logical thinking, clinical reasoning and diagnostic
interpretations (Nair, Shah, Seth, Pandit, & Shah, 2013). The value of a
patient-based learning is also recognised since the beginning of modern medical
education, citing Sir William Osler’s famous quote of “He who studies medicine
without books sails an uncharted sea, but he who studies medicine without
patients does not go to sea at all” (Prober & Heath, 2012).

In addition, on the premise of CBL’s ability to improve one’s
medical training and hence providing long term benefit to one’s future patients
and society as a whole, one can argue that it is even morally obligated for an
individual to engage in CBL in fulfilment of beneficence, one of the 4 pillars
of medical ethics (Brisson, Neely, Tyler, & Barnard, 2015). Failing which,
one’s ‘inadequate training’ may potentially endanger one’s patients and cause
one to face negligence charges.

against access of NEHR

Opponents argue on the basis that such assess 1) contravenes
an individual’s autonomy, 2) may serve to distract medical students from
personally examining the patients and 3) bypass the need for students to
synthesize clinical information.

Autonomy refers to the respect for patient’s right to
self-determination and it is in part expressed through the law of privacy.
Richard Rognehaugh defines privacy as “the right of individuals 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” (Rognehaugh, 1999). In other words, the right of individuals
to decide to whom and what information about themselves is shared. However, due
to the nature of medical information (which is often full of jargons and collaborative
whereby removal of any component may make interpretation of the remaining data difficult),
it may be prohibitively difficult for a laymen to customise his release of
personal information. Hence patients are often presented with an
‘all-or-nothing’ option – to release all pertinent medical and social
information about themselves or to refrain from it completely, the latter of
which may result in the healthcare team terminating treatment for the patient
to avoid undue risk (Singhealth, 2017). Likewise, it is logistically difficult
to customise what patient information medical students have access to,
therefore often is the case whereby Medical students are able to access most of
the information about the patient the healthcare team has access to as well.
The danger in granting accessibility to medical students (and indeed to anyone
who has access to the information) is that the lack of confidentiality may
result in the disclosure of personally identifiable health information to an
insurer, employer or family member which may in turn engender embarrassment,
discrimination and stigma. 2013 was one such instance when a NUS medical
student tweeted about a patient’s pregnancy and abortion history (Teng, 2013). Such breaches may
in turn precipitate “patient’s anxiety, loss of privacy and perhaps a
reluctance to seek care” (Rothstein, 2010). Hence, one could argue that with such
risks 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 cumbersome
paper notes to read and understand about a patient’s case, hence eliciting
information 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, thereby
potentially reducing the need to personally examine the patient. Peled and
Sagher observed that such a change have brought about a transformation of the
architecture of the patient care setting – from teacher and student examining
documents and engaging one another, to rows of physicians and students lining
the walls staring into computer screens (Peled, Sagher, Morrow, & Dobbie, 2009); or what is
colloquially termed “paper rounds” where rounds are conducted around the
computer rather than physically with the patients in the wards. Such a change
if indeed discourages students from physically engaging in a medical interview
with 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 and
facilitate communication…something magical or mysterious…that cannot be
described or taught” (Lichstein, 1990). This is not to mention the inability
to carry out physical examination, an indispensable tool in medicine.

Additionally, the access to clinical notes may bypass
students’ need to synthesize clinical information (Peled, Sagher, Morrow, & Dobbie, 2009). Prior to EHRs,
students have to quickly learn how to distil medical information and present
them in a coherent and succinct manner. With the easy access to clinical case
notes and all its summarised findings done by senior clinicians, there may be
less incentives for students to think critically and summarise the findings
gathered. This can be done by simply imitating what has already be summarised
in the system, thereby again impeding one’s medical education.

As seen above, there is evidently a tension between medical
education and patient privacy with compelling arguments both for and against
medical students’ access to patient information. As described, NEHR presents
itself as a powerful educational tool with wide benefits both for physicians
and students. If usage is unregulated and applied unethically however, it has
potential for far reaching consequences. The effectiveness of this tool as a
means of education is only as good as its user. Hence there is a critical need
to properly regulate its usage to maximize outcomes and mitigate its harm. Here
we will examine several ways how this can be done.

and additional proposed measures

To address the issue on respect for patient’s autonomy, a top
down rule-driven and bottom up education on individual professionalism approach
can be adopted. Further sub-dividing the rule-driven approach, legal and
technological aspects can be touched upon to enforce it.

‘Legally’, medical students are oath-bound the moment they
are sworn in to the medical profession – “I solemnly pledge to…respect the
secrets which are confided in me” (WMA, 2017)
– as well as their signing of confidentiality agreements before starting
clinical training in hospitals. Professional misconduct of medical students
hence disposes them to facing disciplinary actions such as suspension or even
expulsion. This is withholding the rights of the victim (patient) to pursue civil
proceedings against the offender (Fong, 2001). Technologically, hospital
administrators have the ability to review individuals’ access of electronic health
records. Hence enforcement of proper usage of the NEHR would generally not be an
issue. Additional technological measures can also be put into place to regulate
degree of information available to authorized users based on pre-established
role-based privileges (Ozair, Jamshed, Sharma, & Aggarwal, 2015). Access for medical
students could be altered such that sensitive medical information not
immediately relevant to their educational objective such as where a patient
stays, the patient’s income etc. are restricted.

It is however often prohibitively difficult to determine the
exact nature of information to censure or allow and what is exactly relevant to
a medical student’s education. It is therefore more critical to properly
educate medical students on medical ethics and proper stewardship over the
privileged information they are afforded by patients, whom have generously
shared their private data yet received minimal or even non-existent clinical contribution
from the beneficiaries (students). A simple act of asking for the patient’s
permission before accessing their records as a result of such an understanding
goes a long way to affirm patient’s autonomy. Having a portal through which
such permissions obtained can be documented would serve to affirm its authenticity.
On top of this, students should only do so with a genuine educational intent
and restrict themselves from accessing information beyond those essential for
education (Brisson, Neely, Tyler, & Barnard, 2015). The rule of
confidentiality and respect for patient’s autonomy must be strictly upheld in
order to instil confidence in patients seeking treatment.

To address the issue of NEHR eroding the fundamentals of good
medical education, strong emphasis should be placed on teaching the hallmarks
of being a good clinician as well as the necessary steps to achieve that. For
instance, using the NEHR as a means to audit diagnostic impressions and
management rather than as a quick means to obtain the ‘answers’ would enable
one to take charge of one’s own education – to independently undertake the
proper rites of a medical interview and then audit oneself based off the
records without having to constantly turn to a senior clinician for
verification. As described by Mcloughlin, one of the characteristic of a failing
medical student is one whom “rarely thinks further ahead than graduation…they
are overly focused on being an acceptable medical student” (Mcloughlin, 2009). A medical student whom only seeks
shortcuts is not able to move beyond the identity of a student when shortcuts
are no longer available. NEHR is a facilitative tool to assist in clinical
reasoning, not a replacement. Misunderstanding this would undermine its
powerful function to augment CBL and instead ironically brings one back to a
pre-CBL era.

With the increasing adoption of EHRs, especially with the
recent 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 electronic
records. Although NEHR offers significant advantages in training medical
students, it is fraught with its own risks if used inappropriately. After
examining both sides of the arguments, we can conclude that access to the
records is indispensable for medical education but not without its defined
limits – guidelines should clearly defined the appropriate obtainment and usage
of such privileged information and be enforced; as well as educating one’s
conduct and stewardship over it. Only then can we justify the progress of
medical education in line with a patient-centric healthcare system.  


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