Ward Lindsay, Innes Michael
Department of Primary Care and General Practice, University of Birmingham.
Br J Gen Pract. 2003 Apr;53(489):293-7.
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.
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.
Qualitative study using semi-structured interviews.
Nineteen patients aged 20 to 65 years from a large training general practice (eight partners) in a deprived area in the West Midlands.
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.
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.
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.
将数据录入电子记录本质上很复杂。原始（纸质）记录中可能出现错误，而数据转移到电子记录时还会出现更多错误。
了解患者对其个人医疗总结的看法，尤其考虑准确性、医患之间的一致程度，以及患者对计算机化和获取其记录的担忧。
采用半结构化访谈的定性研究。
西米德兰兹郡一个贫困地区的一家大型培训全科诊所（有八名合伙人）的19名年龄在20至65岁之间的患者。
同意接受访谈的患者收到一份其电子总结副本，其中包含“当前问题”“重大（非当前）问题”“过敏情况”和“当前用药”。进行了半结构化访谈，并进行录音和转录。采用扎根理论的持续比较法分析数据。
患者将总结视为医生自用的工具。他们期望全科医生（GP）挑选出与其医疗护理相关的信息，保持更新，在需要时能在整个医疗服务体系中快速获取，并适当限制访问权限。他们看到了计算机化在支持医疗连续性方面的潜在益处。此前没有患者要求查看其病历，但大多数人欢迎有机会讨论总结内容、纠正任何错误，并就更能反映其观点的问题描述进行协商。超过一半的总结在讨论后被全科医生修改。
患者信任他们的私人医生，既信任医生作为其病历的保管者，也信任医生作为访问的把关人。全科医疗中的电子医疗总结在令人担忧的程度上不准确。与患者协商可得出更准确的总结，其中包含患者的观点。需要进一步研究以探讨患者参与这一过程的可行性，以及从改善医疗连续性和改善医患关系方面来看可能会带来哪些益处。
