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《21世纪治愈法案》:学术医疗中心住院医师对信息共享变化的看法。

The 21st Century Cures Act: Inpatient Clinician Perceptions of Changes to Information Sharing at an Academic Medical Center.

作者信息

Hamze Mohamad K, Joshi Shubhankar S, Li Yao, Repp Allen B, Jacobs Alicia, McEntee Rachel

机构信息

Department of Medicine, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, USA.

Department of Medicine, University of Vermont Medical Center, Burlington, USA.

出版信息

Cureus. 2023 Jun 9;15(6):e40184. doi: 10.7759/cureus.40184. eCollection 2023 Jun.

Abstract

Introduction To comply with the Information Blocking Rule in the 21st Century Cures Act, many hospitals began to release inpatient electronic health information such as clinical notes and results to patients immediately, starting in April 2021. We sought to understand the perceptions of hospital-based clinicians regarding the impact of these changes in information sharing on clinicians and patients. Materials and methods We developed and distributed an electronic survey to 122 inpatient attending physicians, resident physicians, and physician assistants within the internal medicine and family medicine departments at an academic medical center. The survey asked clinicians to rate their comfort with information-sharing protocols and describe their perceptions of the impact of immediate information sharing on their documentation habits and patient interactions following the implementation of the Cures Act. Results The survey response rate was 37.7% (46/122). Of the respondents, 56.5% felt comfortable with the note-sharing process, 84.8% reported omitting specific information from their notes to prevent patients from reading it, and 39.1% of clinicians agreed that patients have found clinical notes "more confusing than helpful." Conclusions Immediate sharing of electronic health information has the potential to be a powerful tool for communicating with hospitalized patients. However, our results show many hospital-based clinicians report limited comfort with the note-sharing process and perceive it to be confusing to patients. Efforts are needed to educate clinicians regarding information sharing, understand patient and family perspectives, and develop best practices to enhance communication through electronic notes.

摘要

引言 为遵守《21世纪治愈法案》中的信息封锁规定,自2021年4月起,许多医院开始立即向患者发布住院患者的电子健康信息,如临床记录和检查结果。我们试图了解医院临床医生对这些信息共享变化对临床医生和患者影响的看法。

材料与方法 我们开发并向一家学术医疗中心内科和家庭医学科的122名住院主治医师、住院医师和医师助理发放了电子调查问卷。该调查要求临床医生对他们对信息共享协议的舒适度进行评分,并描述他们对《治愈法案》实施后即时信息共享对其记录习惯和患者互动影响的看法。

结果 调查回复率为37.7%(46/122)。在受访者中,56.5%对笔记共享过程感到满意,84.8%报告为防止患者阅读而在笔记中省略特定信息,39.1%的临床医生同意患者认为临床笔记“更令人困惑而非有帮助”。

结论 即时共享电子健康信息有可能成为与住院患者沟通的有力工具。然而,我们的结果显示,许多医院临床医生报告对笔记共享过程的舒适度有限,并认为这对患者来说令人困惑。需要努力对临床医生进行信息共享教育,了解患者和家属的观点,并制定最佳实践以通过电子笔记加强沟通。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8f0e/10329851/1de3a66af428/cureus-0015-00000040184-i01.jpg

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