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Master Thesis

VSM 2 : Gestion de la synthèse médicale des patients en médecine générale, étude descriptive à partir des dossiers informatisés

Abstract : Background. A patient summary is automatically generated from a structured template named “Volet de synthèse médicale” in general practice electronic health records (EHRs).
Objective: To describe the differences between the patient summary document and EHRs.
Methods: After performing tests, the summary worksheet of 90 patients (10 patients per general practitioner) was compared to their EHRs. Present and absent items were coded, according to the French interoperability framework of health information systems. After univariate analysis, a logistic regression was performed to identify factors associated with the absence rate.
Results: 1747 items were present (mean: 19, 1-52 items), whereas 564 were absent (mean: 6, 0-38 items). 50% of the present items were medications: 401 were ended or stopped. The number of medications present in the worksheet was associated with a decreased absence rate (adjusted OR 0.78 [95% CI, 0.68–0.87]; p < 0.001). Medical history was less likely to be documented (adjusted OR 1.13 [95% CI, 1.05–1.24]; p = 0.004). 88 vaccines were in the structured template and 22 in the EHRs, but not of them were reported in the document.
Discussion: The summary worksheet is more focused on cure than person-centered care. Given the lack of physical and cognitive ergonomics, solutions based on the users’ needs should enhance shared decision-making and improve the healthcare professional-patient relationship.
Document type :
Master Thesis
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https://dumas.ccsd.cnrs.fr/dumas-02337786
Contributor : Bibliothèque Universitaire de Médecine Nice <>
Submitted on : Tuesday, October 29, 2019 - 4:12:37 PM
Last modification on : Tuesday, May 26, 2020 - 6:50:40 PM

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2018NICEM023.pdf
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  • HAL Id : dumas-02337786, version 1

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Vincent Bello. VSM 2 : Gestion de la synthèse médicale des patients en médecine générale, étude descriptive à partir des dossiers informatisés. Médecine humaine et pathologie. 2018. ⟨dumas-02337786⟩

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