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Whenever someone is receiving healthcare, whether that’s with their GP, in hospital or in another setting, they’re looked after by lots of different people. In hospital, you might see over twenty different healthcare professionals each day! Because of this, no one person can possibly just remember what’s happened to a patient (and anyway, staff won’t necessarily be working for all of a person’s admission or appointments). To get around this, we have ‘patient records’ or ‘patient notes’, where healthcare staff write down what has happened to enable continuity of care.
Over time, patient records have evolved, from Lloyd George cards (structured paper cards used by GPs until the 1990s) to increasingly complex digital systems. However, it’s worth being aware that almost 80% of NHS trusts still use paper notes in some capacity.
With notes moving online, this means that access can be tracked and logged. At the same time, electronic notes make it easier for someone to access notes of a patient they aren’t caring for: it’s much easier to search a celebrity’s name on an electronic system than it would be to go find out what ward they were on and then grab their paper notes. This is probably part of why there is now a push to crack down on improper access.
There have been several high profile cases of NHS staff accessing notes of patients that they aren’t caring for; this is called ‘improper access’. In most cases, this was staff accessing celebrities’ notes or accessing the notes of people who had been involved in high profile accidents or terrorist events. There are also cases of people accessing their own records on staff logins (which is also a problem!) and accessing records of friends and family.
This then led the NHS to issue new guidance on what kind of access to patient records is unlawful or illegal. There was some concern that this guidance was too restrictive, as it initially suggested access to records for research or audit (when staff review patient records to make sure care delivered is meeting standards) would be prevented, so it was then updated.
You might be wondering why anyone is bothered about healthcare staff accessing patient records. After all, isn’t that their job? To be clear, no one is suggesting that staff accessing records to provide care is unethical (even in high profile cases, someone will be the treating clinician) But there are several important ethical issues you need to consider when thinking about staff accessing records when they don’t need to to provide patient care.
First of all, there’s the issue of public trust. Imagine how you would feel if you found out someone had been reading your very private medical information because they thought it was funny or just out of curiosity. You’d probably feel violated, and you would be less likely to trust healthcare staff would treat you properly in future. In general, as a doctor, it is very important to always act in ways that promote public trust in the profession for this reason.
A second issue to be aware of is medical confidentiality. What this means is that doctors, and other healthcare staff, are responsible for keeping what patients say to them private except in certain very specific circumstances, where keeping information private might result in serious harm to someone. Again, this helps maintain the public’s trust in healthcare as they know they can share private and embarrassing information and it will be kept safe. Even if someone accesses records and doesn’t share information further, confidentiality has still been breached, and the more people have the information the more likely it is that it might leak.
The third issue to consider is that information might be shared in ways that do harm to patients. For example, imagine you look at a family member’s record and see they have cancer. It might feel like the right thing to tell them as soon as possible, but that means they will have been told out of the blue by a family member who doesn’t know what will happen next and can’t offer the right support. It makes the situation much worse and doesn’t actually help anyone.
Finally, people might access records for truly malicious reasons: to obtain someone’s private medical information to blackmail them or share it publically, to sell information to the media or to stalk or hurt somebody. While this is thankfully very rare, it also highlights the importance of tracking who can access patient records and making sure improper access is checked.
Now you understand the issue, it’s worth planning how to answer medical school interview questions on this topic! Some ethical questions that might come up are:
With any interview question on a ‘hot topic’ you want to show a basic understanding of the topic and 2-3 key ethical issues involved. You’ll want to make sure your answer is structured and can show there are multiple sides to the argument (after all, if there weren’t, there wouldn’t be an ethical discussion!). Frameworks like the Four Pillars can be useful to structure your answers, but you don’t have to use them to score highly.
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