Pyper Cecilia, Amery Justin, Watson Marion, Crook Claire
Department of Public Health, University of Oxford, Headington.
Br J Gen Pract. 2004 Jan;54(498):38-43.
Patient access to on-line primary care electronic patient records is being developed nationally. Knowledge of what happens when patients access their electronic records is poor.
To enable 100 patients to access their electronic records for the first time to elicit patients' views and to understand their requirements.
In-depth interviews using semi-structured questionnaires as patients accessed their electronic records, plus a series of focus groups.
Secure facilities for patients to view their primary care records privately.
One hundred patients from a randomised group viewed their on-line electronic records for the first time. The questionnaire and focus groups addressed patients' views on the following topics: ease of use; confidentiality and security; consent to access; accuracy; printing records; expectations regarding content; exploitation of electronic records; receiving new information and bad news.
Most patients found the computer technology used acceptable. The majority found viewing their record useful and understood most of the content, although medical terms and abbreviations required explanation. Patients were concerned about security and confidentiality, including potential exploitation of records. They wanted the facility to give informed consent regarding access and use of data. Many found errors, although most were not medically significant. Many expected more detail and more information. Patients wanted to add personal information.
Patients have strong views on what they find acceptable regarding access to electronic records. Working in partnership with patients to develop systems is essential to their success. Further work is required to address legal and ethical issues of electronic records and to evaluate their impact on patients, health professionals and service provision.
全国范围内正在发展患者获取在线初级保健电子病历的途径。对于患者访问其电子记录时会发生什么情况,了解甚少。
让100名患者首次访问其电子记录,以引出患者的看法并了解他们的需求。
在患者访问其电子记录时,使用半结构化问卷进行深入访谈,并开展一系列焦点小组讨论。
为患者提供私密查看其初级保健记录的安全设施。
从一个随机分组中选取100名患者首次查看其在线电子记录。问卷和焦点小组讨论涉及患者对以下主题的看法:易用性;保密性和安全性;访问同意;准确性;打印记录;对内容的期望;电子记录的利用;接收新信息和坏消息。
大多数患者认为所使用的计算机技术是可以接受的。大多数患者认为查看自己的记录很有用,并且能理解大部分内容,不过医学术语和缩写需要解释。患者担心安全性和保密性,包括记录可能被滥用。他们希望有能就数据访问和使用给予知情同意的设施。许多人发现了错误,尽管大多数在医学上并不重要。许多人期望有更多细节和更多信息。患者希望添加个人信息。
患者对于他们认为可接受访问电子记录的方面有强烈看法。与患者合作开发系统对于系统的成功至关重要。需要进一步开展工作来解决电子记录的法律和伦理问题,并评估其对患者、医疗专业人员和服务提供的影响。