When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship
When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship
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DOI：
10.1136/bmjqs-2015-004697
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发表时间：
2017-04-01
影响因子：
5.4
通讯作者：
Walker, Jan
中科院分区：
文献类型：
--
作者：
Bell, Sigall K.;Mejilla, Roanne;Walker, Jan
背景患者权益倡导者和安全专家鼓励采用透明的健康记录，但怀疑者担心共享笔记可能会冒犯患者、侵蚀信任或促进防御性医学。随着电子健康记录的传播，这些不同的观点引发了关于通过门户与患者共享就诊记录的风险和好处的政策辩论。方法对美国三个地点的99名志愿医生进行预调查和后调查，他们参与了OpenNotes，并对4592名患者进行了后调查，这些患者至少阅读了一份记录并提交了调查问卷。结果患者阅读记录是为了更好地了解情况，因为他们很好奇；大约三分之一的人阅读记录以检查准确性。总体而言，7%(331)的患者报告就他们的笔记联系了他们的医生办公室。在这些人中，29%的人认为错误，85%的人对错误的解决方案感到满意。几乎所有的患者都报告说对他们的医生感觉更好(37%)或相同(62%)。年龄较大(63岁)、男性、非白人、自我报告健康状况一般/较差或受教育程度较低的患者更有可能报告对医生感觉更好。在医生中，26%的人预计病历会出错，44%的人认为患者会不同意病历。一年后，53%的患者认为患者满意度提高，51%的患者认为患者更信任他们。没有人报告要求进行更多的检查或转诊。结论尽管担心错误、冒犯的语言或防御性做法，但总体而言，透明的笔记不会损害医患关系。相反，医生和患者感觉到了关系上的好处。传统上更脆弱的人群--非白人、自我报告健康状况较差的人群以及正规教育年限较短的人群--可能尤其有可能在看完医生的病历后对自己的医生感觉更好。这些发现进一步为有关OpenNotes的辩论提供了信息，表明透明的记录可能会提高患者的满意度、信任度和安全性。
Background Patient advocates and safety experts encourage adoption of transparent health records, but sceptics worry that shared notes may offend patients, erode trust or promote defensive medicine. As electronic health records disseminate, such disparate views fuel policy debates about risks and benefits of sharing visit notes with patients through portals.Methods Presurveys and postsurveys from 99 volunteer doctors at three US sites who participated in OpenNotes and postsurveys from 4592 patients who read at least one note and submitted a survey.Results Patients read notes to be better informed and because they were curious; about a third read them to check accuracy. In total, 7% (331) of patients reported contacting their doctor's office about their note. Of these, 29% perceived an error, and 85% were satisfied with its resolution. Nearly all patients reported feeling better (37%) or the same (62%) about their doctor. Patients who were older (> 63), male, non-white, had fair/poor self-reported health or had less formal education were more likely to report feeling better about their doctor. Among doctors, 26% anticipated documentation errors, and 44% thought patients would disagree with notes. After a year, 53% believed patient satisfaction increased, and 51% thought patients trusted them more. None reported ordering more tests or referrals.Conclusions Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient-doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations-non-white, those with poorer self-reported health and those with fewer years of formal education-may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety.