#1 - There's always a back door. I did some medical records stuff for a while. I looked myself up, just to confirm for myself how trivial it was to do. Yup, there I was. Which is why I insist that all data at rest is encrypted. (I have yet to win this argument.)
#2 - Our "portal" product had access logs for auditing. Plus permissions, consent trees, delegation. The usual features. Alas. We also had a "break the glass" scenario, ostensibly for emergency care, but was more like the happy path. And to my knowledge, during my 6 years, none of our customers ever audited their own logs.
#3 - My SO at the time worked in a hospital and went to another disconnected hospital for care because she knew her coworkers routinely, illegally looked up patient records, and she didn't want them spying on her.