Classic and Digital Anamnesis

• Autor(a) principal: Lino, Luís Henrique Bastos Nunes Simão
• Data de Publicação: 2021
• Tipo de documento: Dissertação
• Idioma: eng
• Título da fonte: Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos)
• Texto Completo: http://hdl.handle.net/10400.6/11359
• topic: Anamnese; Anamnese Digital; Educação Médica; Fluxo de Trabalho; Prática Clínica; Processos Clínicos Eletrónicos; Domínio/Área Científica::Ciências Médicas::Ciências da Saúde::Medicina

Background & Aims With the ever-increasing adoption of Electronic Health Records (EHR) and its varying influence in clinical practice, physician’s adaptability has been strained. Multiple workflow challenges and necessary changes regarding EHR use are identifiable. Anamnesis remains cornerstone for good medical practice, yet how to conduct such practice in this new context is problematic and may need to be analyzed. The conceptualization of a model for the hybridization of classic and digital means of medical history taking or anamnesis may be a relevant part of the solution. This study aims to explore how physicians gather data, how is it integrated, and what factors play a role in the decision-making process from both classic and digital sources – the first relying on the patient and the latter on EHRs. It further attempts to conceptualize digital anamnesis and discuss its hybridization with conventional medical practices. It additionally touches aspects of medical education models regarding EHRs and expectations around them. Methods The study development benefited from the input gathered from systematic review and four interviews conducted to junior interns. Then the survey, aimed at both physicians and medical students with specific questions to each sample, was distributed across hospitals and medical schools via email. Data was collected and integrated, with both quantitative and qualitative data originating from the survey. Results There was a total of 656 observations, from both medical students (n=374) and physicians (n=282). Regarding clinical practice, physicians were divided in two groups, young physicians (n=159) and experienced physicians (n=123), with a cutoff or 35 years old. A huge variability of current medical practices on medical history taking in the context of EHRs was observed. Time usage, data review and entry, and data compatibility with patient-provided information reported said variability. With age being a prevalent factor. EHR education showed major gaps in medical students and junior interns’ curriculum. However, it is seen as highly valued in both cases Current medical practices regarding medical history taking in the context of medical work with EHRs were highly variable. Physicians employed different tactics and workflows while using EHRs without any visible evidence-based adaptation. The conceptualization of a model for Digital Anamnesis, to somehow organize medical history taking through digital tools, such as EHR, maybe helpful for practice and medical education purposes. Based on the systematic review conducted, survey answers and current classic anamnesis frameworks, a model for Digital Anamnesis was conceptualized, with regards to data review and entry. Three interconnected aspects of digital medical history can be identified. The first being the content to be discovered in the EHR, which equates to the virtual construct of the patient in EHR data (iPatient) and background information regarding past medical history, family, personal and social history, drug and allergy history. The second, are the process skills for exploration of data, such as computer literacy and skills, multitasking management, data selection for note review and entry and documentation managing. Lastly, EHR-specific characteristics that influent user interface, data management and system interoperability. Nonetheless, digital anamnesis benefits from its integration with classic anamnesis. For that, development, and testing of different teaching models, based in virtual and simulation components can be conducted within medical schools and with junior interns. Clinical and simulation-based medical education can further develop EHR skills both in communication and proficiency. EHR proficiency skills are also related with data management and can impact physicians work habits. Aiming for a better understanding of the issues that affect EHR data and uniformization of EHR data entry can decrease physicians’ workload and fatigue. Medical education should focus on the integration between digital and classic anamnesis. Future physicians will rely increasingly on EHRs and major gaps regarding education on EHR use were identified. Further work should be done in creating models for classic and digital anamnesis integration that could be implemented in medical education and practice. It is recommended further educational opportunities to be created towards EHR simulation its integration in medical curriculum.