Original Title: Confidencialidad de la historia clínica. Análisis de la situación actual y áreas de mejora en el uso y manejo de la misma

Authors' objectives: To determine the opinions and attitudes of Osakidetza (Basque health service) professionals with regard to the confidentiality of clinical histories with the aim of establishing those areas in which their management might be improved.

Authors' results and conclusions: A summary was made of the comments made in the focus groups and the results of direct observation. The basic contents, consisting of the results of the survey, were divided into discoveries relating to: the «awareness» of professionals of the need to ensure confidentiality, their «attitudes» in situations in which maintaining confidentiality is not easy and, lastly, their «opinions» about the difficulties they have fulfilling their confidentiality obligations in their daily work. All the results were presented in the form of charts to facilitate their comprehension. Moreover, a number of additional comments made by some of the professionals who filled in the questionnaire were added and sorted according to subject matter. We found a clear demand for training and information, although this varied according to professional group or work area. The awareness of the importance of this subject is greater in Mental Health. The area in which the highest number of problems were found was in Specialised Care. A large majority of health professionals are in agreement with the fact that the basic problem of maintaining the confidentiality of clinical records is the human factor, and that the most worrying aspect is the problem of gossip. The professionals who answered the questionnaire prefer electronic clinical histories to traditional printed records.

Authors' recommendations: It is necessary to emphasise the importance of training professionals, involving middle management and making them responsible for passing on information. It would be interesting to work with Care Ethics Committees to create workgroups in each centre in order to analyse points of conflict and to search for potential areas for improvement.

Authors' methods: This survey has been carried out in three stages: In the first stage, a) the most relevant literature was reviewed, b) the subject was discussed in specific workgroups corresponding to several different areas (Primary Care, Specialised Care, Mental health and Management) and c), five focus groups were formed (with patience, Primary Care professionals, Specialised Care, Mental Health and Management). Moreover, direct observation was maintained in a number of health care areas. With the information obtained during the three stages, a questionnaire was drawn up and sent to a random sample of all the workers in the Basque health service, stratified according to professional category and work area. In total, 3,367 questionnaires were sent, of which 824 valid questionnaires were returned. Following the statistical analysis and discussion of the information obtained from these questionnaires, suitable recommendations were drawn up.

Project Status: Completed

Year Published: 2009

URL for published report: https://www.euskadi.eus/contenidos/informacion/2009_osteba_publicacion/es_def/adjuntos/d_09_03_confi_hist_cli.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Basque Office for Health Technology Assessment (OSTEBA)</p>