Electronic medical summaries in general practice--considering the patient's contribution.

BACKGROUND

Data entry into electronic records is intrinsically complex. Errors may occur in the primary (paper) record and further errors when data is transferred to the electronic record.

AIMS

To elicit patients' ideas about their personal medical summaries, specifically considering accuracy, level of agreement between doctors and patients, and patients' concerns about computerisation and access to their records.

DESIGN OF STUDY

Qualitative study using semi-structured interviews.

SETTING

Nineteen patients aged 20 to 65 years from a large training general practice (eight partners) in a deprived area in the West Midlands.

METHOD

Patients agreeing to be interviewed were mailed a copy of their electronic summary, which contained 'active problems', 'significant (not active) problems', 'allergies', and 'present medication'. Semi-structured interviews were conducted, which were tape recorded and transcribed. The constant comparative method of grounded theory was used to analyse the data.

RESULTS

Patients saw the summaries as a tool for the doctor's own use. They expected their general practitioners (GPs) to select the information relevant for their medical care, keep it updated, make it quickly available across the health service where needed, and limit access appropriately. The saw potential benefits of computerisation in supporting continuity of care. No patients had previously asked to see their notes, but most welcomed the opportunity to discuss the content of the summaries, correct any errors, and negotiate a description of problems that more closely reflected their perspective. Over half of the summaries were altered by the GP after discussion.

CONCLUSIONS

Patients trust their personal doctors, both as caretakers of their notes and as gatekeepers for access. Electronic medical summaries in general practice are inaccurate to a worrying extent. Negotiation with patients can result in a more accurate summary that includes the patient's perspective. Further studies are needed to look at the feasibility of patient participation in such a process and to see what benefits, in terms of improved continuity of care and improved doctor-patient relationship, may result.