Patel Vimla L, Arocha José F, Kushniruk André W
Department of Medical Informatics, Decision Making and Cognition, Columbia Presbyterian Medical Center, Columbia University, 622 West 168th Street, New York, NY 10032-372, USA.
J Biomed Inform. 2002 Feb;35(1):8-16. doi: 10.1016/s1532-0464(02)00002-3.
The aim of this paper is to examine knowledge organization and reasoning strategies involved in physician-patient communication and to consider how these are affected by the use of computer tools, in particular, electronic medical record (EMR) systems.
In the first part of the paper, we summarize results from a study in which patients were interviewed before their interactions with physicians and where physician-patient interactions were recorded and analyzed to evaluate patients' and physicians' understanding of the patient problem. We give a detailed presentation of one of such interaction, with characterizations of physician and patient models. In a second set of studies, the contents of both paper and EMRs were compared and in addition, physician-patient interactions (involving the use of EMR technology) were video recorded and analyzed to assess physicians' information gathering and knowledge organization for medical decision-making.
Physicians explained the patient problems in terms of causal pathophysiological knowledge underlying the disease (disease model), whereas patients explained them in terms of narrative structures of illness (illness model). The data-driven nature of the traditional physician-patient interaction allows physicians to capture the temporal flow of events and to document key aspects of the patients' narratives. Use of electronic medical records was found to influence the way patient data were gathered, resulting in information loss and disruption of temporal sequence of events in assessing patient problem.
The physician-patient interview allows physicians to capture crucial aspects of the patient's illness model, which are necessary for understanding the problem from the patients' perspective. Use of computer-based patient record technology may lead to a loss of this relevant information. As a consequence, designers of such systems should take into account information relevant to the patient comprehension of medical problems, which will influence their compliance.
本文旨在研究医患沟通中涉及的知识组织和推理策略，并探讨这些因素如何受到计算机工具（特别是电子病历系统）使用的影响。
在本文的第一部分，我们总结了一项研究的结果。在该研究中，患者在与医生互动之前接受了访谈，并且医患互动被记录和分析，以评估患者和医生对患者问题的理解。我们详细展示了其中一次互动，并刻画了医生和患者模型。在第二组研究中，对纸质病历和电子病历的内容进行了比较，此外，还对涉及使用电子病历技术的医患互动进行了视频记录和分析，以评估医生在医疗决策中的信息收集和知识组织情况。
医生根据疾病潜在的因果病理生理学知识（疾病模型）来解释患者问题，而患者则根据疾病的叙事结构（疾病模型）来解释。传统医患互动的数据驱动性质使医生能够捕捉事件的时间流程，并记录患者叙述的关键方面。研究发现，电子病历的使用会影响患者数据的收集方式，导致在评估患者问题时出现信息丢失和事件时间顺序的中断。
医患面谈使医生能够捕捉患者疾病模型的关键方面，这对于从患者角度理解问题是必要的。使用基于计算机的患者记录技术可能会导致这些相关信息的丢失。因此，此类系统的设计者应考虑与患者对医疗问题理解相关的信息，这将影响他们的依从性。
