What are the benefits brought to the parties with doctors by showing medical records to patients?

BySean Lamb

When you receive medical consultation at a hospital or clinic, doctors usually take notes from the patient while listening to the symptoms. Normally, doctors and patients do not often see a medical record together, but one American doctor shared a patient with a patient, an unexpected advantage was born.

When Patients Read What Their Doctors Write: Shots - Health News: NPR

George Washington UniversityEmergency medical centerLeana WenA doctor took a note while stroking a patient one day while hitting the keyboard as usual. Then the patient asked, "Can I have you show me what I am writing?" Wen asked the doctor "I want you to show what it is written" was the first time that I was touched by myself for a moment, but I thought that there should be no reason not to show the chart, While showing the display, I explained what was being written.

ByAlex Proimos

When Dr. Wen explains, the patient points out the mistake written in the medical record, "It began three weeks before not the last week I started to feel pain." In addition, although it was described as "past abuse of alcohol" as a medical record in the past, the patient who saw it revealed to Wen doctor that the patient resumed excessive drinking a few months due to stress.

The suspicion that the patient's condition is a pancreas caused by overdose of alcohol was strengthened by performing a medical examination while showing a medical chart, and it was said that it was useful for subsequent treatment as a result of examination at an early stage. Since Wen's doctor was taught that a medical record is shared by multiple medical institutions to make communication easier, he did not think that there is merit in sharing with patients .

In 1966Health Insurance Portability and Accountability ActBefore the HIPAA (HIPAA: Medical Insurance Interoperability and Accountability Act) was enacted, in the United States patients can view medical records only when a patient filed a lawsuit against a medical institution. HIPAA is a law that contains clauses that give patients the right to view medical records, enacted allowing patients to read charts more easily than before, but still it is a hassle to browse charts It was necessary to go through such procedures.

ByAlex Proimos

However, in 2010, two physicians, Tom Delbanco physician and nurse Jan Walker who is a nurse and researcher,OpenNotes"A doctor started an experiment sharing a medical record with a patient. The hypotheses established at that time can be treated in conjunction with the patient by sharing the medical record with the patient.

In response to the experiments that both began, we received great opposition from other doctors who were afraid of "patient misunderstanding the charts and understanding" "patients tend to sue", but after the experiment Approximately 80% of the patients who participated deeply understood the disease condition, responded that consciousness concerning health care increased, and about 66% got the prescription taking the prescription as instructed. And 99% of patients wanted to share medical records with doctors in the future. Some doctors who participated in the experiment also asked, "By having the patient read the charts, I could build a stronger relationship of trust than before."


Not only experiments, OpenNotes spread to hospitals and clinics throughout the United States, and in 2014 it will bring about a big movement to receive financial assistance from foundation foundations. However, it is also true that there are doctors who continue to show their opposition to OpenNotes. Doctors such as psychiatrists and psychosomatic doctors say that they should hesitate to show all of the medical records to the patient. There are also opinions that patients may wonder the possibility of duplicating charts and publishing medical records information on SNS.

So, in terms of whether the patient can view the medical record in Japan, the medical record as personal information, the first section of the law concerning the protection of personal informationArticle 25 of "Obligation of business operator handling personal information"It is stipulated as follows.

Article 25 An entrepreneur handling personal information shall disclose personally identifiable information to be identified by himself / herself (including notifying the fact that there is no retained personal data identifying the principal, The same shall apply), when it is requested, the relevant personal data must be disclosed to the principal, without delay, by the method specified by Cabinet Order. Provided, however, that if it falls under any of the following items, it may not disclose all or part of it.
When there is a risk of harming the life, body, property or other rights and interests of one person or a third party
(Ii) When there is a risk of significant hindrance to the proper implementation of the business of the person handling personal information
(Iii) In the case of violating other laws and regulations

In accordance with the Personal Information Protection Act enforced in April 2005, medical institutions are positioned as businesses handling personal information.

Basic knowledge of medical ethics | To the doctor | To the doctor | Public benefit corporation Japan Medical Association

In other words, a doctor who is recognized as a business handling personal information handles is obliged to disclose the medical record when requested from the patient unless it falls under the above three items. Actually, in Japan too many hospitals disclose medical records to patients, there is nothing wrong with asking patients to show medical chart during medical treatment.

in Note, Posted by darkhorse_log