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患者对最终放射学报告的电子访问:当前的实践标准是什么,是否有适当的封发期?

Patient Electronic Access to Final Radiology Reports: What Is the Current Standard of Practice, and Is an Embargo Period Appropriate?

机构信息

From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar St, TE2, New Haven, CT 06520 (J.L.M., C.L., H.P.F.); Yale University, New Haven, Conn (G.J., L.Y.); and Yale Law School, New Haven, Conn (C.L.).

出版信息

Radiology. 2021 Jul;300(1):187-189. doi: 10.1148/radiol.2021204382. Epub 2021 May 4.

Abstract

Patients have a right to their medical records, and it has become commonplace for institutions to set up online portals through which patients can access their electronic health information, including radiology reports. However, institutional approaches vary on how and when such access is provided. Many institutions have advocated built-in "embargo" periods, during which radiology reports are not immediately released to patients, to give ordering clinicians the opportunity to first receive, review, and discuss the radiology report with their patients. To understand current practices, a telephone survey was conducted of 83 hospitals identified in the 2019-2020 Best Hospitals Rankings. Of 70 respondents, 91% (64 of 70) offered online portal access. Forty-two percent of those with online access (27 of 64 respondents) reported a delay of 4 days or longer, and 52% (33 of 64 respondents) indicated that they first send reports for review by the referring clinician before releasing to the patient. This demonstrates a lack of standardized practice in prompt patient access to health records, which may soon be mandated under the final rule of the 21st Century Cures Act. This article discusses considerations and potential benefits of early access for patients, radiologists, and primary care physicians in communicating health information and providing patient-centered care. © RSNA, 2021.

摘要

患者有权获取自己的病历,医疗机构建立在线门户,患者可通过该门户获取其电子健康信息,包括放射科报告,这种做法已十分普遍。然而,在提供访问权限的方式和时间方面,各医疗机构的做法存在差异。许多医疗机构提倡内置“封存”期,在此期间,放射科报告不会立即提供给患者,以便让开单临床医生有机会先接收、查看并与患者讨论放射科报告。为了了解当前的实践情况,对在 2019-2020 年《美国新闻与世界报道》最佳医院排名中确定的 83 家医院进行了电话调查。在 70 名回复者中,91%(64/70)提供在线门户访问。在有在线访问权限的受访者中(64 名中的 27 名),42%报告存在 4 天或更长时间的延迟,52%(64 名中的 33 名)表示他们会先将报告发送给开单临床医生审核,然后再提供给患者。这表明在患者快速获取健康记录方面缺乏标准化做法,而根据《21 世纪治愈法案》的最终规定,这种做法可能很快会被强制要求。本文讨论了患者、放射科医生和初级保健医生在交流健康信息和提供以患者为中心的护理方面尽早获取信息的考虑因素和潜在益处。©RSNA,2021 年。

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