Author: dr. Brian Fisher, GP, London

Patients’ record access is here to stay. It is available now in many countries and is gradually extending across the world. There are different systems, through smart cards, kiosks in GP waiting rooms and online.

The reason for this is clear – it is safe and very helpful for patients and for clinicians. The benefits often overlap – what is good for patients is also helpful for professionals. I write this paper from the basis of experience – I have been showing my patients their records for over 20 years now. In the last year, we have been doing this online. We have carried out extensive research in the field. Our learning can help you proceed more safely and more swiftly.

Some of the benefits and risks do depend on what the system of access allows. We therefore feel, on the basis of the evidence, that the ideal process should allow:

• Access to the full electronic record
• The ability to view whenever andwherever the patient wants
• The patient should be able to be reminded of key heath appointments
• The patient should be bale to screen off information that they do not want selected professionals to see.

So, what are the benefits and the risks?

Benefits for patients
The benefits of RA appear to be substantial. Patients describe improved trust and confidence in their clinicians, [1] and they feel more informed and in control of their condition and its management [2]. There is some evidence for improved health practices by patients – for example, improved compliance in heart failure [3] and improved cigarette quit rates [4].

In general, patients are keen on RA in principle [5] and in practice [6]. RA can increase safety by patients correcting recording errors [7]. Furthermore, patients can save time for practices and themselves by looking in their records for information rather than asking reception.

In our recent experience, we have also found that:

• Elderly patients have been sharing records with their carers, enabling far better coordinationand understanding
• People have been accessing their records when ill abroad to show foreignclinicians
• Patients have left the surgery not really understanding what I have told them – they can easily look up what I have written about them and understand it more clearly.
• They can also remind themselves ofinstructions
• They have access to personalised and targeted health information

Risks for patients
International research confirms the safety of record access. Nonetheless, there are issues that need to be faced. If access is online, there are risks of patients being coerced to reveal information – by family members or others.

We know that patients with psychiatric problems have difficulties reading their records because they often get upset by what they see, however, they continue to champion record access because they can see that it is the right thing to do.

The system must ensure that patients do not see frightening information without support or information. Letters or results should not be read by patients before the clinician has seen them.

There is an important issue about children – at what age should parents stop seeing their children’s records, and how can system design support whatever solution is most appropriate?

Just to repeat, however, risks to patients are minor – the benefits are really overwhelming.

Benefits of record access to clinicians
Our experience over 20 years has shown a wide range of benefits. They can be enhanced by particular system design, so the particular advantages will depend on which system is used. The online system enables patients to see everything that the practice holds on them electronically – letters, consultations, results, problem lists.

Soon, it will also be possible to alert patients to important appointment s that they need to make – BP, or diabetic reviews, for instance.

So, the benefits to the practices are:

• Efficiency: patients obtaining test results and hospital letters withouthaving to contact the practice.
• Clarity: patients can look at the consultations and bothremember what we said, but also sometimes understand better what we said
• Safety: errors can becorrected, making the record more accurate. Because patients can share records across clinicians this enormously enhancescommunication and safety.
• The process is time neutral: we know now that record access does notresult in longer consultations
• Effectiveness: patients understand their conditions better and thereis evidence, outlined above, that this aids compliance and health promoting behaviour. There is also generic evidence thatpatients who understand their condition, have better outcomes and use health services less.

Risks to clinicians
The risks are few, but they can feel large. Clinicians do have worries about record access, but most of these can be easily allayed.

They mainly centre on patients seeing third party information. Third party information means: “information about the index patient given to the clinician by a non-clinician”. For instance, information given to a GP by the wife telling the clinician that the husband drinks – the wife does not want the clinician to reveal the source of the information.

Our experience of this is that, with careful and legal recording this is not a risk except in very exceptional circumstances.

One system will soon be able to support practices who wish to, in enabling access to consultations only from a certain date, before which the practice will have decided on exactly how to record 3rd party information making the risk very small.

There are concerns that clinicians may have to write records differently. The prime use of the record is for communication between clinicians. Our experience is that little change is needed, but the clearer we write, the easier it is for patients.

There are worries over litigation – there is no evidence that increased access leads to increased litigation. In both Denmark and the US, when access laws were changed, litigation rates did not alter. It is possible that, because relationships improve, litigation rates may in fact decrease.

There are concerns that patients with serious illnesses may be so upset when reading their records that this in itself would pose a risk to their health. There is no evidence to support this [8].

In summary
Experience across the world is very encouraging – the process has enormous benefits for patients and practices. WE all gain and increasingly work together.

References:
[1] Baldry M., Cheal C., Fisher B., Gillett M., Huet V. [1986]. “Giving Patients their own records in general practice: experience of patients and staff”. Br Med J [Clin Res Ed] Mar 86, 1;292[6520]:596-8
[2] Pyper C, Amery J, Watson M, Crook C.,[ 2004]. “Patients’ experiences when accessing their on-line electronic patient records in primary care”, Br J Gen Pract. Jan;54[498]:38-43.
[3] Ross SE, Moore LA, Earnest MA, Wittevrongel L, Lin CT. [May 2004] Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial. J Med Internet Res. 20;6[2]:e14.
[4] Bronson DL, O’Meara K. The impact of shared medical records on smoking awareness and behavior in ambulatory care. J Gen Intern Med. 1986 Jan-Feb; 1[1]:34-7
[5] National Programme for IT, [7 October 2003.] “The public view on electronic health records”, available from: http://www.dh.gov.uk/assetRoot/04/05/50/46/04055046.pdf
[6] Pyper C, Amery J, Watson M, Crook C., [2004] “Access to electronic health records in primary care-a survey of patients’ views”, Med Sci Monit.Nov;10[11]:SR17-22.
[7] Powell J, Fitton R, Fitton C. [2006] Sharing electronic health records: the patient view. Informatics in Primary Care 14:55-7
[8] Baldry M., Cheal C., Fisher B., Gillett M., Huet V. [1986]. “Giving Patients their own records in general practice: experience of patients and staff”. Br Med J [Clin Res Ed] Mar 86, 1;292[6520]:596-8

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