DesRoches Catherine M
Harvard Medical School, OpenNotes, Boston, MA, USA.
Semin Dial. 2020 Nov;33(6):533-538. doi: 10.1111/sdi.12934. Epub 2020 Nov 19.
Debates around access to and ownership of an individual's digital information have taken center stage in health care. A decade ago, the idea of offering patients ready access to their clinical notes was a fringe idea. Today, information transparency in health care is a pressing legislative and regulatory issue in the United States and elsewhere. The 21st Century Cures Act of 2016 requires that clinicians and health care organizations give patients electronic access to the information in their electronic medical records. Rules to enact this legislative priority by the Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services substantially expanded the types of information that must be easily accessible to patients and exchanged among clinicians in electronic form. A growing body of research supports the notion that sharing transparent medical records, including clinical notes with patients, can help to strengthen communication, trust in clinicians, and patient engagement. Patients receiving dialysis may receive particular benefits from this greater transparency due to their increased risk for fragmented care. In the paper, we review the decade of research focused on the effects of sharing clinical notes with patients and the implications for improved engagement and care.
围绕个人数字信息的获取和所有权的争论在医疗保健领域已成为核心问题。十年前，为患者提供随时获取其临床记录的想法还是个边缘想法。如今，医疗保健中的信息透明度在美国和其他地方都是一个紧迫的立法和监管问题。2016年的《21世纪治愈法案》要求临床医生和医疗保健机构让患者能够以电子方式获取其电子病历中的信息。卫生信息技术国家协调办公室和医疗保险与医疗补助服务中心为落实这一立法重点而制定的规则，大幅扩大了患者必须能够轻松获取并由临床医生以电子形式交换的信息类型。越来越多的研究支持这样一种观点，即与患者共享透明的医疗记录，包括临床记录，有助于加强沟通、增进对临床医生的信任以及提高患者参与度。接受透析的患者可能会因护理碎片化风险增加而从这种更高的透明度中获得特别的益处。在本文中，我们回顾了十年来专注于与患者共享临床记录的影响以及对改善参与度和护理的意义的研究。
