Petersson Lena, Erlingsdóttir Gudbjörg
Faculty of Engineering, Department of Design Sciences, Lund University, Lund, Sweden.
JMIR Ment Health. 2018 Feb 2;5(1):e11. doi: 10.2196/mental.9140.
When the Swedish version of Open Notes, an electronic health record (EHR) service that allows patients online access, was introduced in hospitals, primary care, and specialized care in 2012, psychiatric care was exempt. This was because psychiatric notes were considered too sensitive for patient access. However, as the first region in Sweden, Region Skåne added adult psychiatry to its Open Notes service in 2015. This made it possible to carry out a unique baseline study to investigate how different health care professionals (HCPs) in adult psychiatric care in the region expect Open Notes to impact their patients and their practice. This is the first of two papers about the implementation of Open Notes in adult psychiatric care in Region Skåne.
The objective of this study was to describe, compare, and discuss how different HCPs in adult psychiatric care in Region Skåne expect Open Notes to impact their patients and their own practice.
A full population Web-based questionnaire was distributed to psychiatric care professionals in Region Skåne in late 2015. The response rate was 28.86% (871/3017). Analyses show that the respondents were representative of the staff as a whole. A statistical analysis examined the relationships between different professionals and attitudes to the Open Notes service.
The results show that the psychiatric HCPs are generally of the opinion that the service would affect their own practice and their patients negatively. The most striking result was that more than 60% of both doctors (80/132, 60.6%) and psychologists (55/90, 61%) were concerned that they would be less candid in their documentation in the future.
Open Notes can increase the transparency between patients and psychiatric HCPs because patients are able to access their EHRs online without delay and thus, can read notes that have not yet been approved by the responsible HCP. This may be one explanation as to why HCPs are concerned that the service will affect both their own work and their patients.
2012年，瑞典引入了“开放病历”（Open Notes）这一电子健康记录（EHR）服务，允许患者在线访问其病历，但精神科护理被排除在外。这是因为精神科病历被认为对患者访问来说过于敏感。然而，作为瑞典的首个地区，斯科讷地区（Region Skåne）于2015年将成人精神病学纳入其“开放病历”服务。这使得开展一项独特的基线研究成为可能，以调查该地区成人精神科护理中不同的医疗保健专业人员（HCPs）期望“开放病历”如何影响他们的患者及其实践。这是关于斯科讷地区成人精神科护理中“开放病历”实施情况的两篇论文中的第一篇。
本研究的目的是描述、比较和讨论斯科讷地区成人精神科护理中不同的医疗保健专业人员期望“开放病历”如何影响他们的患者及自身实践。
2015年末，向斯科讷地区的精神科护理专业人员发放了一份基于网络的全员调查问卷。回复率为28.86%（871/3017）。分析表明，受访者代表了全体工作人员。一项统计分析研究了不同专业人员与对“开放病历”服务态度之间的关系。
结果显示，精神科医疗保健专业人员普遍认为该服务会对他们自身的实践和患者产生负面影响。最显著的结果是，超过60%的医生（80/132，60.6%）和心理学家（55/90，61%）担心他们未来在记录中会不够坦诚。
“开放病历”可以提高患者与精神科医疗保健专业人员之间的透明度，因为患者能够立即在线访问其电子健康记录，从而可以阅读尚未得到负责的医疗保健专业人员批准的记录。这可能是医疗保健专业人员担心该服务会影响他们自己的工作和患者的一个原因。
