【背景】多疾患併存状態高齢患者に関し在宅療養後方支援病院が提供する診療情報の質向上を目指し、在宅医・病院医双方の経験を持つ医師に質問紙調査を行った。
【方法】関連医学系学会を介する告知により50名の協力を得た。卒後7-33年、病院勤務・訪問診療各6-10年の経験を持つ医師が最多（26%）、地域別では関東甲信越(40%)に北海道・東北と中部(各16%)が続いた。
【結果】患者の病状理解（44%）、主介護者の介護力（34%）、治療・病状（33%）、処方に対応する疾患名（33%）に係る問題が報告され、患者（全身状態・現住所）・家族（在宅移行の希望度合い）、検査結果（抗生剤感受性）・画像、治療（HOT流量）・投薬（退院時処方との齟齬）に関する不備、主科以外からの情報欠落、（主症状以外の疾患）悪化時の対応未記載等の実例を得た。
これらの不備の原因としては、病院医は在宅医療を想像できない、目前の仕事しか関心がない、ケアの重要性を知らない、状態安定と思い込む、退院間近は観察が不十分になる、看護師・相談員しか会議に参加しない、リハビリ病院を介すと情報が失われる等の見解が示された。
上記場面での追加情報収集先としては、患者・家族（46%）、他職種（MSW）・看護要約（41%）、紹介元主治医（書面照会）（38%）が挙げられた。
回答者が適切な情報共有手段として選んだのは（退院カンファレンス39% 診療情報提供書36%; 病診共通診療録32%)の順に多かった。質問紙で提示した方法に加え、メール・電話、退院日患者面接、提供書の（施設毎または地域別）標準化、全職種要約の一覧化(A3一枚程度)、在宅医による院内多職種カンファレンスへの（遠隔）参加、在宅医が必要情報を自律的に得られる仕組み、在宅医側から病院医への高齢者診療の本質共有、多疾患併存状態やプライマリ・ケアに特化した人材育成等が提案された。
【考察・結論】病院医向けチェックリスト策定を当初目的とした本研究において、その範囲を超える提案を得たことは大変意義深い。次の課題としては病院医経験のみを持つ医師の見解を得る機会を設け、各案の妥当性・実現可能性を在宅療養後方支援病院の視点で検討することが望まれる。
Background: A questionnaire survey was conducted among physicians with experience as both home care physicians and hospital physicians, to improve the quality of medical information on elderly patients with multimorbidity provided by home care support hospitals.

Methods: An announcement about the survey was made through medical societies in relevant area and 50 physicians expressed their willingness to participate. The physicians had 7-33 years of postgraduate experience, and there was a high percentage of physicians with both 6-10 years of experience in hospitals and 6-10 years of experience in home care (26%). The physicians came predominantly from the Kanto-Koshinetsu region (40%), followed by Hokkaido/Tohoku (16%) and Chubu (16%).

Results: Problems related to patients' understanding of their condition (44%), ability of primary caregivers to provide care (34%), diagnosis and treatment (33%), and diagnosis corresponding to prescription (33%) were reported, and examples of incomplete information on patients (general condition, present address)/their families (to what extent they wished for the patient to receive home care), test results (sensitivity to antibiotics)/images, treatment (home oxygen therapy [HOT] flow rate) / medication (inconsistency with prescription at discharge), missing information from departments other than the main department, and unrecorded treatment at exacerbation (of diseases other than the main symptom) were obtained.
The respondents provided the following views on the incomplete information: hospital physicians cannot imagine home care, are interested only in the work at hand, do not know the importance of home care, take it for granted that the patient's condition is stable, and do not observe the patient closely immediately before discharge; only nurses and counselors participate in meetings; and information is lost on its way through rehabilitation hospitals. In the above situations, some sources of additional information were the patients/their families (46%), other professionals (medical social workers [MSW]). / nursing summary (41%), and attending physicians who initially referred the patients (written inquiries) (38%).
As appropriate information-sharing methods, discharge conferences were selected by the largest number of the respondents (39%), followed by medical information provision forms (36%) and common hospital-clinic medical records (32%). In addition to the methods presented in the questionnaire, e-mail/telephone, patient interviews on the day of discharge, standardization of information provision forms (for each medical institution or region), summarization of the lists provided by all professionals (approximately one sheet of A3 paper), home care physicians' (remote) participation in in-hospital multidisciplinary conferences, a system that would allow home care physicians to autonomously obtain the necessary information, home care physicians' sharing of the essence of elderly care with hospital physicians, and development of human resources focused on patients with multimorbidity or primary care were proposed.

Discussion / Conclusion In this survey, with the original purpose of developing a checklist for hospital physicians, it is very significant that unexpected proposals were obtained. In the future, it is desirable to obtain the views of physicians with experience only as hospital physicians and to evaluate the validity and feasibility of each proposal from the standpoint of home care support hospitals.