Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA.
Eye (Lond). 2022 Oct;36(10):1951-1958. doi: 10.1038/s41433-021-01775-9. Epub 2021 Oct 5.
The implementation of OpenNotes and corresponding increase in patient access to medical records requires thorough assessment of the risks and benefits of note-sharing. Ophthalmology notes are unique among medical records in that they extensively utilize non-standardized abbreviations and drawings; they are often indecipherable even to highly-educated clinicians outside of ophthalmology. No studies to date have assessed ophthalmologist perceptions of OpenNotes.
A cross-sectional study was conducted from 4/28 to 5/12/2016. A survey was distributed to 30 clinicians (25 ophthalmologists, three optometrists, two nurses) in the University of Colorado's Department of Ophthalmology to evaluate provider attitudes towards granting patients access to online medical records.
Many clinicians felt patients would have difficulty understanding their records and may be unnecessarily alarmed or offended by them. Some clinicians worried their workload would increase and feared having to change the way they document. Perceived benefits of OpenNotes included improving patient understanding of their medical conditions, strengthening patient-physician trust, and enhancing patient care. Many perceived risks and benefits of note-sharing were associated with conceptions of the ideal clinician-patient relationship.
Clinicians in ophthalmology perceived both benefits and consequences of increasing patient access to ophthalmic records, and there were significant correlations between these perceptions and their conceptions of the clinician-patient relationship. This is the first study to assess potential ophthalmology provider attitudes toward sharing ophthalmic records. Although limited in sample size and power, this study demonstrates some ways patient-accessible ophthalmic records can affect the clinical practice of ophthalmology and emphasizes the unique challenges of OpenNotes in ophthalmology.
OpenNotes 的实施以及由此带来的患者对病历的访问权限增加，需要对共享记录的风险和益处进行彻底评估。眼科记录在病历中独具特色，因为它们广泛使用非标准化的缩写和图表；即使对于眼科以外的受过高等教育的临床医生来说，这些记录也常常难以辨认。迄今为止，还没有研究评估过眼科医生对 OpenNotes 的看法。
本研究于 2016 年 4 月 28 日至 5 月 12 日进行了一项横断面研究。向科罗拉多大学眼科系的 30 名临床医生（25 名眼科医生、3 名验光师、2 名护士）分发了一份调查，以评估临床医生对向患者提供在线病历访问权限的态度。
许多临床医生认为患者可能难以理解他们的记录，并且可能会不必要地感到担忧或受到冒犯。一些临床医生担心他们的工作量会增加，并担心必须改变记录方式。OpenNotes 的预期益处包括提高患者对其医疗状况的理解，增强患者与医生之间的信任，并改善患者护理。许多人认为共享记录的益处和风险与理想的医患关系观念有关。
眼科临床医生对增加患者对眼科记录的访问权限既看到了好处，也看到了后果，并且这些看法与他们对医患关系的看法之间存在显著相关性。这是第一项评估潜在眼科医生对分享眼科记录的态度的研究。尽管样本量和效力有限，但本研究展示了一些患者可访问的眼科记录可以影响眼科临床实践的方式，并强调了 OpenNotes 在眼科领域的独特挑战。
