Problem: Confidentiality Borders

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Electronic health-care records must implement and respect confidentiality settings, such that certain care givers will not be able to view information that the patient may not want them to. There are many aspects to this problem, such as if the doctor should be able to break these confidentiality barriers in emergency situations, if the existence of hidden data should be indicated, and so on, but the only problem we will discuss in this section is to what entity the confidentiality is applied.

Currently, in Sweden at least, confidentiality is applied to entities such as care provider, document, referral, record notations, warnings, and prescriptions. Exactly which elements you can apply confidentiality attributes to, varies according to EHR system vendor.

The reason confidentiality has to be applied to all these peripheral data types is because the element you actually need to apply confidentiality to, the disease as such, does not exist in these systems. This explains both why there are so many complicated rules and elements and why it will always result in error.

Applying confidentiality causes different problems in each of these cases. A very short list of problems and dangers follows:

  • If applied to care provider, any non-confidential actions performed by that care provider will be hidden behind the confidentiality shroud as well. Also, any action taken by any other, non-included care provider for the confidential disease, will not be hidden and will divulge the existence of the condition. Something as simple as a general practitioner renewing a prescription for a drug used in schizophrenia, for example, will divulge the existence of the condition, regardless of the wishes of the patient.
  • If applied to prescriptions, the doctor will be unable to check for interactions and contraindications, resulting in outright danger to the patient. If the patient develops liver disease or renal failure or any other condition that would make a prescribed but confidential medication dangerous, the doctor will not know about that. The current EHR systems are also unable to warn for contraindications in these situations, since they have no concept of diseases or contraindications.
  • If applied to warnings, such as chronic infections, it puts medical staff at risk by not alerting them to the necessity of taking extra precautions while working with the patient
  • If applied to investigations, referrals, lab results, etc, then the same kind of dangers occur. Since the EHR is unaware of diseases as concepts, it is also totally unable to draw any conclusions on its own and issue warnings for possible medical errors due to the hiding of information.

The only medically responsible conclusion you can draw is that it is dangerous to apply any confidentiality of any kind to current medical health-care records. There is no way these systems can hide information in a way that makes the risk of serious error low enough to be acceptable. Sadly, the law mandates these confidentiality mechanisms, clearly prioritizing the patient's right to confidentiality above medical safety. Personally, I don't know if this is right or wrong, but the lawmaker is placed in the unenviable position of having to make such a choice by the unnecessarily poor design of current EHR systems.