Should Medical Students Track Former Patients in the Electronic Health Record? An Emerging Ethical Conflict

Abstract

Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.

Erosion of Digital Professionalism During Medical Students’ Core Clinical Clerkships

“…However, it is unlikely that all patients would consider their records to be open to all to view, even when coming to teaching hospitals. Others have written on this potential ethical dilemma [22-24]. Furthermore, it appears from other data that some students are accessing their previous patients’ records for curiosity rather than more educationally related reasons.…”

Two years of unintended consequences: introducing an electronic health record system in a hospice in Scotland

“…Ethical issues arise over who should have access to information (Brisson et al . ), and how secure the data may be within the record (Ozair et al . ).…”

“…In some cases, patient safety has been compromised by poorly planned implementation (Kaplan & Harris-Salamone 2009). Ethical issues arise over who should have access to information (Brisson et al 2015), and how secure the data may be within the record (Ozair et al 2015). Professional cultural issues emerge from the challenge to the way each health discipline has historically recorded and communicated the patient story within health records (Struck 2013).…”

A Framework for Tracking Former Patients in the Electronic Health Record Using an Educational Registry

“…[3][4][5][6][7] One educational application of EHRs involves Btracking^patients, defined as following up on former patients in the EHR for educational purposes after they have left one's direct care. 8 Tracking provides access to patients' future clinical data, enabling students to audit their diagnostic impressions, 5 observe outcomes, and develop deliberate practice patterns by offering feedback on questions such as, BDid we really need to order that?^7…”

“…Students find tracking educationally beneficial, 9 but there is a risk to patient privacy associated with unlimited access to patient records. 8,10 Horwitch has recommended that medical schools provide guidance on Bhow to do this that would not violate ethical or HIPAA requirements.^1 1 In this paper we describe a framework for tracking using an Beducational registry^(EdR): a list of former patients housed within the EHR that one follows longitudinally for educational purposes. Our goal was to develop a tracking method that safeguards patient privacy while preserving the learning opportunities.…”