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首页> 外文期刊>Journal of medical Internet research >Patient Experiences With Full Electronic Access to Health Records and Clinical Notes Through the My HealtheVet Personal Health Record Pilot: Qualitative Study
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Patient Experiences With Full Electronic Access to Health Records and Clinical Notes Through the My HealtheVet Personal Health Record Pilot: Qualitative Study

机译：通过My HealtheVet个人健康记录试点以完全电子方式访问健康记录和临床记录的患者体验：定性研究

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Background: Full sharing of the electronic health record with patients has been identified as an important opportunity to engage patients in their health and health care. The My HealtheVet Pilot, the initial personal health record of the US Department of Veterans Affairs, allowed patients and their delegates to view and download content in their electronic health record, including clinical notes, laboratory tests, and imaging reports.Objective: A qualitative study with purposeful sampling sought to examine patients’ views and experiences with reading their health records, including their clinical notes, online.Methods: Five focus group sessions were conducted with patients and family members who enrolled in the My HealtheVet Pilot at the Portland Veterans Administration Medical Center, Oregon. A total of 30 patients enrolled in the My HealtheVet Pilot, and 6 family members who had accessed and viewed their electronic health records participated in the sessions.Results: Four themes characterized patient experiences with reading the full complement of their health information. Patients felt that seeing their records positively affected communication with providers and the health system, enhanced knowledge of their health and improved self-care, and allowed for greater participation in the quality of their care such as follow-up of abnormal test results or decision-making on when to seek care. While some patients felt that seeing previously undisclosed information, derogatory language, or inconsistencies in their notes caused challenges, they overwhelmingly felt that having more, rather than less, of their health record information provided benefits.Conclusions: Patients and their delegates had predominantly positive experiences with health record transparency and the open sharing of notes and test results. Viewing their records appears to empower patients and enhance their contributions to care, calling into question common provider concerns about the effect of full record access on patient well-being. While shared records may or may not impact overall clinic workload, it is likely to change providers’ work, necessitating new types of skills to communicate and partner with patients.
机译：背景：与患者充分共享电子健康记录已被认为是使患者参与其健康和保健的重要机会。 My HealtheVet Pilot是美国退伍军人事务部的初始个人健康记录，可让患者及其代表查看和下载其电子健康记录中的内容，包括临床笔记，实验室检查和影像报告。方法：通过对参加波特兰退伍军人管理局医学部My HealthVet Pilot的患者和家属进行的五次焦点小组会议，研究患者在网上阅读其健康记录（包括临床笔记）的看法和经验。俄勒冈州中心。共有30位患者参加了My HealtheVet Pilot，有6位访问并查看了其电子健康记录的家庭成员参加了会议。结果：四个主题表征了患者阅读完整健康信息的经历。患者感到，看到他们的记录对与医疗提供者和卫生系统的沟通产生了积极影响，增强了他们对健康的知识并改善了自我保健，并允许他们更多地参与其护理质量，例如随访异常检查结果或做出决定。在何时寻求护理。虽然有些患者认为看到以前未公开的信息，贬义的语言或笔记不一致会带来挑战，但他们绝大多数还是认为拥有更多而不是更少的健康记录信息会有所裨益。健康记录的透明度以及笔记和测试结果的公开共享。查看他们的记录似乎可以增强患者的权能并增强他们对护理的贡献，这使普通医疗服务提供者担心完全访问记录对患者福祉的影响。尽管共享记录可能会或可能不会影响整个诊所的工作量，但很可能会改变提供者的工作，从而需要新的技能类型来与患者交流和合作。

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