Ross Stephen E, Lin Chen-Tan
Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, CO, USA.
J Am Med Inform Assoc. 2003 Mar-Apr;10(2):129-38. doi: 10.1197/jamia.m1147.
The Health Insurance Privacy and Portability Act (HIPPA) stipulates that patients must be permitted to review and amend their medical records. As information technology makes medical records more accessible to patients, it may become more commonplace for patients to review their records routinely. This article analyzes the potential benefits and drawbacks of facilitating patient access to the medical record by reviewing previously published research. Previous research includes analysis of clinical notes, surveys of patients and practitioners, and studies of patient-accessible medical records. Overall, studies suggest the potential for modest benefits (for instance, in enhancing doctor-patient communication). Risks (for instance, increasing patient worry or confusion) appear to be minimal in medical patients. The studies, however, were of limited quality and low statistical power to detect the variety of outcomes that may result from implementation of a patient-accessible medical record. The data from these studies lay the foundation for future research.
《健康保险隐私与可携性法案》（HIPPA）规定，必须允许患者查阅和修改自己的病历。随着信息技术使患者更容易获取病历，患者定期查阅自己的病历可能会变得更加普遍。本文通过回顾先前发表的研究，分析了便利患者获取病历的潜在益处和弊端。先前的研究包括对临床记录的分析、对患者和从业者的调查，以及对患者可访问的病历的研究。总体而言，研究表明存在适度益处的可能性（例如，在加强医患沟通方面）。在医疗患者中，风险（例如，增加患者的担忧或困惑）似乎最小。然而，这些研究的质量有限，统计能力较低，无法检测出实施患者可访问病历可能产生的各种结果。这些研究的数据为未来的研究奠定了基础。
