To the Editor:
We appreciate the Commentary by McLaughlin and Coderre1 on our Perspective addressing ethical concerns associated with tracking former patients in electronic health records (EHRs).2 Their focus on learning theory is an important contribution to the discussion of how best to use EHRs in training. However, tracking is associated with important ethical concerns, and their conclusion that these are adequately managed through the rule of confidentiality leaves unaddressed the concomitant risk to patient privacy.
Privacy is the ability of a patient to control personal information, while confidentiality is the commitment of the physician to the patient to control information about the patient.3 And while confidentiality is an ancient ethical principle in medicine, privacy is a modern principle.
What is troubling and difficult to appreciate about tracking is that it relates to the future: When patients grant access to their EHR, they recognize that clinicians, including physicians in training, may see everything that has already happened; what they may not realize is that, where tracking is allowed, they have unwittingly granted access to future events, including new and potentially sensitive information which may be completely unrelated to students’ educational objectives. Despite the learning potential and assurance that students are bound by confidentiality, that new information was not explicitly part of the privacy bargain that the patient struck in accepting the student as part of the care team—and patients have a right to control access to that new information.
When requesting broad access to a patient’s EHR, students should be clear about the nature of that request. And when patients agree, students (indeed, all clinicians) must conduct themselves according to the highest ethical standard to assure proper stewardship of this privilege. We believe that guidelines on tracking, based on principles of medical ethics adapted to contemporary challenges, will reduce risk by safeguarding patient privacy.
Finally, McLaughlin and Coderre comment that “rather than advancing this [tracking] as a learning strategy … the authors discuss the potential for ethical conflict.” In fact, the primary goal of our paper was to advance tracking as a learning strategy by addressing the ethical issues associated with it; the two issues are related, and we believe that ambiguity regarding the appropriateness of tracking has likely hindered its evolution as a learning tool. Frankly, if not conducted within an explicitly patient-respectful framework, it can feel like snooping. Our paper is intended to raise awareness of tracking and address the ethical conflict between privacy and education so that it can evolve as a learning tool in a manner which places patients’ interests first.
Gregory E. Brisson, MD
Assistant professor in clinical medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; firstname.lastname@example.org.
Kathy Johnson Neely, MD
Assistant professor in medicine, Feinberg School of Medicine, Northwestern University, and chair, Medical Ethics Committee, Northwestern Memorial Hospital, Chicago, Illinois.
Patrick D. Tyler, MD
First-year resident, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Cynthia Barnard, MBA, MSJS
Director, Quality Strategies, Northwestern Memorial Hospital, and research associate professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
1. McLaughlin K, Coderre S. Finding the middle path in tracking former patients in the electronic health record for the purpose of learning. Acad Med. 2015;90:1007–1009
2. Brisson GE, Neely KJ, Tyler PD, Barnard C. Should medical students track former patients in the electronic health record? An emerging ethical conflict. Acad Med. 2015;90:1020–1024
3. Winkelstein PChen H, Fuller SS, Friedman C, Hersh W. Ethical and social challenges of electronic health information. Medical Informatics: Knowledge Management and Data Mining in Biomedicine. 2005 New York, NY Springer:144–145