SMA's comments on proposed guidelines on appropriate use and access to National Electronic Health Records (NEHR)





SMA thanks the Ministry of Health for giving us the opportunity to give feedback on the proposed guidelines on appropriate use and access to NEHR. We agree that these guidelines would be a useful reference for all healthcare professionals when contributing to, accessing or using NEHR.


We would suggest that similar guidelines be formulated and promulgated for other parties who have access to NEHR, such as NEHR administrators and government bodies.


We agree that access to NEHR should only be granted to those who are required to consult NEHR for the purposes of patient care, and not for non-care related purposes such as employment, insurance and research. (Page 8 - 4.1.2 Access to NEHR).


We support the guidance that history taking and physical examination should remain the primary approach in clinical assessment, and that NEHR is a complementary tool to aid clinical assessment. We agree that where a healthcare professional is satisfied that the information provided through the patients history and their examination is sufficient for them to assess and treat the patient, there is no requirement to consult NEHR. (Page 10 - 5.1.1 Scope of Use of NEHR)




Our concerns about the proposed guidelines are as follows:


Page 4 - 2.2 Impetus for these guidelines


This discusses the main purpose of NEHR - which is to unleash the full potential of NEHR for caregivers when they access NEHR. We hold the view that it is important to balance the aim of unleashing the full potential with the rights and preferences of the patient, which, even if he does not own the data in NEHR, is the source that produced the information.


Page 5 - 2.3.1 Key Principles


There is mention of "Medical Confidentiality", but no mention of the Healthcare Privacy Rights of the patient. A document as important as this that does not explicitly mention, state or acknowledge that the patient has privacy rights as a key principle is at best unfinished, unbalanced and incomplete.


In order for the patient to retain his privacy rights, NEHR must allow the patient to:

  • Opt out of uploading of any, or all information into NEHR

  • Select which information already in his NEHR record, he would like to share with his doctor.


Page 6 - (bottom of page, footnote) and Page 11 - 5.1.4 Handling sensitive health information


The fact that the existing system allows healthcare professionals to access sensitive health information (SHI) without explicit approval from the patient is disconcerting if not alarming. We agree that where possible, healthcare professionals should explain to their patients why they think they need to access this information to provide better patient care. We hold the view that healthcare professionals should refrain from accessing this information if the patient refuses access, except in emergency situations.  It is important that the patient should be able to specify which portions (or all) of the SHI in his record he wishes to share, to maintain the same privacy rights as face-to-face briefing during history taking in the current doctor-patient consultation.


Page 7 - 3.1.2 Revisions and addendums to medical records


We agree that errors in the NEHR records should be corrected. However it is too onerous for the healthcare professional who picks up the error, to contact the user who made the error. It would suffice that the healthcare professional informs the NEHR administrator of the error and let the NEHR administrator sort it out.


Page 7 - 3.1.3 Handling of patient information which may have higher confidentiality requirements


The document does not elaborate how to handle confidential information. It seems to imply that healthcare professionals could omit entering confidential information into their EMR, the implied reason being that this confidentiality would be compromised once the information is uploaded into NEHR.  We are extremely uncomfortable with this suggestion.  


The SMC Ethical Code and Ethical Guidelines states: 

"Your medical records must include all clinical details about your patients, discussions of investigation and treatment options, informed consents, results of tests and treatments and other material information. If you are delegated an aspect of care, you may confine your records to what is relevant to your portion of care.

If patients request for information not to be documented, you may accede to their requests but you must be sure that this does not adversely impact their care or the safety of others."


Most confidential information that is divulged by patients in the course of history taking is relevant for patient care, and can be documented with the patient’s permission, after reassuring the patient that the information will be kept private and confidential.  


We hold the view that the solution is not for healthcare professionals to omit entering confidential information into their EMR, it is to block the upload of such information into NEHR if the patient requests it.


Page 11 - 5.1.4 Handling Sensitive Health Information


Here, it states that the healthcare professional should only "inform". We would add that if the patient refuses access to his SHI, the healthcare professional should not proceed to do.


Comments on scenarios


We understand that the scenarios are meant to be illustrative and not meant to represent the standard of care that healthcare professionals have to follow. We request that this be clearly stated in the document.


Scenario F, in which a nursing home checks NEHR to assess patient's suitability for admission to the nursing home, is highly inappropriate, NEHR should only be accessed by licensed healthcare providers. We think in this instance the patient should give consent in writing in order for the licensed healthcare provider in the nursing home to access his NEHR. 


Scenario G, in which a GP did not deem it necessary to review NEHR in his management of a patient with a common cold. This scenario is too vague to illustrate the need to rely on professional judgment to determine if access to NEHR is required. Already, the statement made was that the GP did not deem it necessary to review NEHR.



Above all, SMA asks that patient privacy rights are included in the key principles of how to use NEHR, and that the implementation of NEHR empowers the patient to exercise those rights. Thank you very much for considering our feedback.