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首页> 外文期刊>BMC Medical Informatics and Decision Making >Underutilization of information and knowledge in everyday medical practice: Evaluation of a computer-based solution
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Underutilization of information and knowledge in everyday medical practice: Evaluation of a computer-based solution

机译：日常医疗实践中信息和知识的未充分利用：基于计算机的解决方案的评估

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Background The medical history is acknowledged as the sine qua non for quality medical care because recognizing problems is pre-requisite for managing them. Medical histories typically are incomplete and inaccurate, however. We show here that computers are a solution to this issue of information gathering about patients. Computers can be programmed to acquire more complete medical histories with greater detail across a range of acute and chronic issues than physician histories. Methods Histories were acquired by physicians in the usual way and by a computer program interacting directly with patients. Decision-making of what medical issues were queried by computer were made internally by the software, including determination of the chief complaint. The selection of patients was from admissions to the Robert-Bosch-Hospital, Stuttgart, Germany by convenience sampling. Physician-acquired and computer-acquired histories were compared on a patient-by-patient basis for 45 patients. Results The computer histories reported 160 problems not recorded in physician histories or slightly more than 3.5 problems per patient. However, physicians but not the computer reported 13 problems. The data show that computer histories reported problems across a range of organ systems, that the problems detected by computer but not physician histories were both acute and chronic and that the computer histories detected a significant number of issues important for preventing further morbidity. Conclusion A combination of physician and computer-acquired histories, in non-emergent situations, with the latter available to the physician at the time he or she sees the patient, is a far superior method for collecting historical data than the physician interview alone.
机译：背景技术病史被认为是高质量医疗的必要条件，因为认识到问题是管理问题的前提。但是，病史通常是不完整和不准确的。我们在这里表明，计算机是解决有关患者信息收集问题的一种解决方案。可以对计算机进行编程，以获取比医师历史记录更完整的完整医学历史记录，其中包括有关急诊和慢性病的详细信息。方法历史记录是由医生以通常的方式并通过与患者直接互动的计算机程序获取的。该软件在内部对计算机查询哪些医疗问题做出决策，包括确定主要投诉。患者的选择是通过方便抽样从入院到德国斯图加特的罗伯特-博世医院。在45位患者的基础上，比较了医师获得的和计算机获得的历史。结果计算机历史记录报告了160个未记录在医生历史记录中的问题，或每位患者略多于3.5个问题。但是，医生而非计算机报告了13个问题。数据表明，计算机历史记录报告了一系列器官系统的问题，计算机发现的问题（而非医师历史记录）都是急性和慢性的，并且计算机历史记录检测到许多对防止进一步发病至关重要的问题。结论在非紧急情况下，结合医生和计算机获取的历史记录，以及在他或她见到患者时可供医生使用的历史记录，是一种比单独进行医生采访更好的收集历史数据的方法。

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