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保留患者故事:从传统病历到数字病历转变的生物伦理与法律影响

Preserving Patient Stories: Bioethical and Legal Implications Related to the Shift from Traditional to Digital Anamnesis.

作者信息

Gibelli Filippo, Bailo Paolo, Pesel Giuliano, Ricci Giovanna

机构信息

Section of Legal Medicine, School of Law, University of Camerino, 62032 Camerino, Italy.

出版信息

Clin Pract. 2024 Jun 21;14(4):1196-1213. doi: 10.3390/clinpract14040095.

DOI:10.3390/clinpract14040095
PMID:39051289
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11270254/
Abstract

It is since the beginning of the so-called 'digital revolution' in the 1950s that technological tools have been developed to simplify and optimise traditional, time-consuming, and laborious anamnestic collection for many physicians. In recent years, more and more sophisticated 'automated' anamnestic collection systems have been developed, to the extent that they can actually enter daily clinical practice. This article not only provides a historical overview of the evolution of such tools, but also explores the ethical and medico-legal implications of the transition from traditional to digital anamnesis, including the protection of data confidentiality, the preservation of the communicative effectiveness of the doctor-patient dialogue and the safety of care in patients with poor digital and health literacy.

摘要

自20世纪50年代所谓的“数字革命”开始以来,人们开发了各种技术工具,以简化和优化许多医生传统的、耗时费力的问诊过程。近年来,越来越复杂的“自动化”问诊收集系统得以开发,甚至可以实际应用于日常临床实践。本文不仅提供了此类工具演变的历史概述,还探讨了从传统问诊向数字问诊转变所涉及的伦理和医学法律问题,包括数据保密性保护、医患对话沟通有效性的维护,以及数字和健康素养较低患者的医疗安全。

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本文引用的文献

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Digital literacy as a new determinant of health: A scoping review.数字素养作为健康的新决定因素:一项范围综述。
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The role of digital literacy in achieving health equity in the third millennium society: A literature review.数字素养在实现第三个千年社会健康公平中的作用:文献综述。
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Digital Tools Designed to Obtain the History of Present Illness From Patients: Scoping Review.数字工具设计用于从患者获取现病史:范围综述。
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Internet of Things (IoT) enabled healthcare helps to take the challenges of COVID-19 Pandemic.物联网支持的医疗保健有助于应对新冠疫情带来的挑战。
J Oral Biol Craniofac Res. 2021 Apr-Jun;11(2):209-214. doi: 10.1016/j.jobcr.2021.01.015. Epub 2021 Jan 30.
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Structured Digital Self-Assessment of Patient Anamnesis Prior to Computed Tomography: Performance Evaluation and Added Value.计算机断层扫描前患者病史的结构化数字自我评估:性能评估与附加价值
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Impact of a Commercial Artificial Intelligence-Driven Patient Self-Assessment Solution on Waiting Times at General Internal Medicine Outpatient Departments: Retrospective Study.商业人工智能驱动的患者自我评估解决方案对普通内科门诊候诊时间的影响:回顾性研究
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[Usability and Efficiency of a Digital Communication Assistance Tool to Obtain Medical History from Non-German-Speaking Patients].[一种用于从非德语患者获取病史的数字通信辅助工具的可用性和效率]
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A Digital Communication Assistance Tool (DCAT) toObtain Medical History from Foreign-LanguagePatients: Development and Pilot Testing in a PrimaryHealth Care Center for Refugees.一种用于从外语患者获取病史的数字通信辅助工具(DCAT):在难民初级保健中心的开发和试点测试。
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A prospective cohort study of self-reported computerised medical history taking for acute chest pain: protocol of the CLEOS-Chest Pain Danderyd Study (CLEOS-CPDS).一项针对急性胸痛的自我报告计算机化病历采集的前瞻性队列研究:Danderyd 研究(CLEOS-CPDS)的 CLEOS-Chest Pain 研究方案。
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