Contesting everyday violence: Resilience pathways of gay and transgender youth in Peru.

Within Peru, lesbian, gay, bisexual, transgender, intersex, and queer/questioning (LGBTIQ) groups experience significant levels of violence, particularly LGBTIQ youth. This study explored youth responses to violence in two cities: Lima and Ayacucho. We sought to formulate key factors facilitating LGBTIQ youth resilience to inform local practice and policy. Focus groups were conducted with youth that self-identified as gay and transgender. We used thematic analysis to identify both inductive and deductive themes. Deductive themes were driven from resilience and structural violence theories. Structural and direct violence was reported by all youth with differences regarding the role of self, place and people in their resilience pathways. Despite experiencing everyday violence, LGBTIQ youth participants displayed remarkable resilience, though the resilience strategies and experiences of violence were distinctive for each group. Transgender youth relied more on their collective rather than individual resilience. In contrast, gay youth revealed a high level of individual resilience. Overall, the participants exhibited a fluidity of resilient and resistant behaviours toward violence. The use of place theory and a social resistance framework is suggested for interventions that effectively honour and foster the courageous resilience of LGBTIQ youth and effectively equalize their opportunities.

A Qualitative Evaluation of Contact Centre Dietitian Support and Electronic Motivational Messaging for eaTracker My Goals Users.

PURPOSE: To conduct a qualitative evaluation of adjunct supports (brief motivational messaging regarding goals delivered by email/website, contact centre dietitian assistance) offered by EatRight Ontario (ERO) for users of a website-based nutrition/activity goal setting/tracking feature (eaTracker "My Goals"). METHODS: One-on-one semi-structured interviews were conducted with My Goals users in Ontario (n = 18) and Alberta (n = 5) recruited via the eaTracker website and ERO contact centre dietitians (n = 5). Interview transcripts were analyzed using content analysis. RESULTS: Participants had mixed experiences and perspectives with ERO motivational messaging. Messages targeted towards specific goals (e.g., tips, recipes) were generally well-liked, and generic messages (e.g., eaTracker login reminders) were less useful. No interviewed users had contacted ERO dietitians regarding goals, and dietitians reported encountering few callers asking for assistance while using My Goals. Limited user knowledge was one explanation for this finding. Participants provided suggestions to enhance these supports. CONCLUSION: Electronic motivational messaging and contact centre dietitian assistance have the potential to support achievement of goals set with website-based features. When considering using electronic messaging, researchers and practitioners should consider message content and delivery tailoring. Marketing that focuses on how contact centre dietitians can assist website users with their goals is needed when services are used in naturalistic settings.

Experiences and Perceptions of Adults Accessing Publicly Available Nutrition Behavior-Change Mobile Apps for Weight Management.

BACKGROUND: Nutrition mobile apps have become accessible and popular weight-management tools available to the general public. To date, much of the research has focused on quantitative outcomes with these tools (eg, weight loss); little is known about user experiences and perceptions of these tools when used outside of a research trial environment. OBJECTIVE: Our aim was to understand the experiences and perceptions of adult volunteers who have used publicly available mobile apps to support nutrition behavior change for weight management. DESIGN: We conducted one-on-one semi-structured interviews with individuals who reported using nutrition mobile apps for weight management outside of a research setting. PARTICIPANTS/SETTING: Twenty-four healthy adults (n=19 females, n=5 males) who had used publicly available nutrition mobile apps for weight management for ≥1 week within the past 3 to 4 months were recruited from the community in southern Ontario and Edmonton, Canada, using different methods (eg, social media, posters, and word of mouth). QUALITATIVE DATA ANALYSIS: Interviews were audiorecorded, transcribed verbatim, and transcripts were verified against recordings. Data were coded inductively and organized into categories using NVivo, version 10 (QSR International). RESULTS: Participants used nutrition apps for various amounts of time (mean=approximately 14 months). Varied nutrition apps were used; however, MyFitnessPal was the most common. In the interviews, the following four categories of experiences with nutrition apps became apparent: food data entry (database, data entry methods, portion size, and complex foods); accountability, feedback, and progress (goal setting, accountability, monitoring, and feedback); technical and app-related factors; and personal factors (self-motivation, privacy, knowledge, and obsession). Most participants used apps without professional or dietitian support. CONCLUSIONS: This work reveals that numerous factors affect use and ongoing adherence to use of nutrition mobile apps. These data are relevant to professionals looking to better assist individuals using these tools, as well as developers looking to develop new and improved apps.

The website-based eaTracker® 'My Goals' feature: a qualitative evaluation.

OBJECTIVE: In 2011, Dietitians of Canada added 'My Goals' to its website-based nutrition/activity tracking program (eaTracker®, http://www.eaTracker.ca/); this feature allows users to choose 'ready-made' or 'write-your-own' goals and to self-report progress. The purpose of the present study was to document experiences and perceptions of goal setting and My Goals, and report users' feedback on what is needed in future website-based goal setting/tracking tools. DESIGN: One-on-one semi-structured interviews were conducted with (i) My Goals users and (ii) dietitians providing a public information support service, EatRight Ontario (ERO). SETTING: My Goals users from Ontario and Alberta, Canada were recruited via an eaTracker website pop-up box; ERO dietitians working in Ontario, Canada were recruited via ERO. SUBJECTS: My Goals users (n 23; age 19-70 years; 91 % female; n 5 from Alberta/n 18 from Ontario) and ERO dietitians (n 5). RESULTS: Dietitians and users felt goal setting for nutrition (and activity) behaviour change was both a beneficial and a challenging process. Dietitians were concerned about users setting poor-quality goals and users felt it was difficult to stick to their goals. Both users and dietitians were enthusiastic about the My Goals concept, but felt the current feature had limitations that affected use. Dietitians and users provided suggestions to improve My Goals (e.g. more prominent presence of My Goals in eaTracker; assistance with goal setting; automated personalized feedback). CONCLUSIONS: Dietitians and users shared similar perspectives on the My Goals feature and both felt goal use was challenging. Several suggestions were provided to enhance My Goals that are relevant to website-based goal setting/tracking tool design in general.

What is consumer health informatics? A systematic review of published definitions.

BACKGROUND: Consumer health informatics (CHI) is an emerging field that utilizes technology to provide health information to enhance health-care decision making by the public. There is, however, no widely accepted or uniform definition of CHI. A consensus definition would be important for pedagogical reasons, to build capacity and to reduce confusion about what the discipline consists of. AIM: We undertook a systematic review of published definitions of CHI and evaluated them using five quality assessment criteria and measures of similarity. METHODS: Five databases were searched (Embase, Web of Science, MEDLINE, CINAHL and Business Source Complete) resulting in 1101 citations. Twenty-three studies met the inclusion criteria. Definitions were appraised using five criteria (with each scoring out of one): use of published citation, multi-disciplinarity, journal impact, definition comprehensibility, text readability. RESULTS: Most definitions scored low on citation (Mean ± SD: 0.22 ± 0.42), multi-disciplinarity (0.15 ± 0.28) and readability (0.04 ± 0.21) and somewhat higher on IF (0.35 ± 0.45) and definition comprehensibility (idea density) (0.87 ± 0.34) criteria. Overall, the quality of the published definitions was low 1.63 ± 0.80 (out of five). CONCLUSIONS: The definitions of CHI were variable in terms of the quality assessment criteria. This suggests the need for continued discussion amongst consumer health informaticians to develop a clear consensus definition about CHI.

An open debate about the object and purpose of global health knowledge in the context of an interdisciplinary research partnership on HIV/STI prevention priorities in Peru.

BACKGROUND: With the failure of the latest vaccine trial, HVTN-505, HIV prevention efforts remain critical. Social and structural factors contributing to HIV and STI transmission include stigma regarding sexual violence, HIV infection and sexual orientation. For instance, HIV prevention and overall sexual health programs in Peru have been implemented yet key populations of youth (sex workers, male and transgender youth) continue to be overrepresented in new cases of HIV and STI. This suggests that interventions must take new directions and highlights the need for additional research. DISCUSSION: While interdisciplinary, international research collaborations often are indicated as best practice in developing new knowledge in global health and an important component of the leadership in health systems, this does not mean they are free of challenges. In this debate we document our reflections on some of the challenges in developing an interdisciplinary and international research team to understand HIV and STI prevention priorities among youth in two culturally diverse cities in Peru: Lima, the capital city, and Ayacucho, in the Andean region. SUMMARY: Rather than offering solutions we aim to contribute to the debate about the object and purpose of global health research in the context of developing international research partnerships that genuinely promote a reciprocal and bidirectional flow of knowledge between the Global South and the Global North, and researchers at intersections of these locations.

A survey of public health and consumer health informatics programmes and courses in Canadian universities and colleges.

INTRODUCTION: As information technology becomes more widely used by people for health-care decisions, training in consumer and public health informatics will be important for health practitioners working directly with the public. METHODS: Using information from 74 universities and colleges across Canada, we searched websites and online calendars for programmes (undergraduate, graduate) regarding availability and scope of education in programmes, courses and topics geared to public health and/or consumer health informatics. RESULTS: Of the 74 institutions searched, 31 provided some content relevant to health informatics (HI) and 8 institutions offered full HI-related programmes. Of these 8 HI programmes, only 1 course was identified with content relevant to public health informatics and 1 with content about consumer health informatics. Some institutions (n = 22) - which do not offer HI-degree programmes - provide health informatics-related courses, including one on consumer health informatics. We found few programmes, courses or topic areas within courses in Canadian universities and colleges that focus on consumer or public health informatics education. DISCUSSION: Given the increasing emphasis on personal responsibility for health and health-care decision-making, skills training for health professionals who help consumers navigate the Internet should be considered in health informatics education.

Comprehension of Internet-based numeric cancer information by older adults.

Competency in health numeracy is essential in understanding risk about disease susceptibility and the consequences of disease treatment. Both health literacy and skill in using the Internet to obtain health information are lower among older compared with younger adults. Presentation format of health information has been shown to influence comprehension. The objective of this study was to determine the influence of information formatting (text and graphic) on older adults' comprehension of Internet-based numeric cancer risk information. This cross-sectional study involved a convenience sample of adults, aged 50 years and older from diverse ethnic and educational backgrounds. Cancer risk information, obtained from a Canadian Cancer Society web page, was presented as text, graphics or as a combination of text and graphics formats. Comprehension of the information was assessed by six questions focused on basic numeracy skill and ability to perform simple calculations and operations. A three-item general context numeracy and an eight-item health context numeracy instrument were used to describe health numeracy skills of participants. The six-item Newest Vital Sign (NVS) test was used to assess prose and numeric health literacy. There was no statistically significant effect of presentation format on participants' comprehension of the cancer information. Participants' comprehension of basic health numeracy information was positively correlated with education (p < or = 0.05) and income (p < or = 0.01) whereas comprehension of information that assessed calculation and operations numeracy skill was positively correlated only with income (p < or = 0.05). Health literacy skill and income explained a significant proportion of the variance in overall comprehension of Internet-based cancer risk information (R(2) = 0.414, p < or = 0.01) in this sample of older adults. Format of numeric risk information was not a significant factor in the comprehension of cancer risk information in this group of ethnically diverse, older adults. However, comprehension of the information was related to health literacy skill and income.

Creating case scenarios or vignettes using factorial study design methods.

AIM: This paper is a report of a study conducted to develop clinical case vignettes using an adaptation of an incomplete factorial study design methodology. BACKGROUND: In health care, vignettes or cases scenarios are core to problem-based learning, common in practice guideline development processes, and increasingly being used in patient or care-giver studies of chronic or life-threatening illnesses. A large number of behavioural, psycho-social and clinical factors can be relevant in such decision problems. Unbiased methods for choosing what factors to include are needed, when it is not possible to include all relevant combinations of factors in the vignettes. METHOD: The factors to be considered, number of levels or categories for each factor, and desired number of scenarios were decided in advance. An algorithm was used first to create the full factorial data set, and then a random subset of combinations was generated, according to predefined criteria, based on maximizing determinants. The subset of combinations was incorporated into written vignettes. The study was conducted in 2004-2005. FINDINGS: Application of the method yielded diverse and balanced scenarios that covered the full range of factors to be considered for a project to elicit health providers' processes in diet counselling for dyslipidemia. CONCLUSION: The approach is flexible, decreases possible researcher bias in the creation of vignettes, and can improve statistical power in survey research. This novel application of study design methodology merits consideration when vignettes are being developed to elicit opinions or decisions in studies of complex health issues.

Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education.

Theoretical and methodological advances in the cognitive and learning sciences can greatly inform curriculum and instruction in biomedicine and also educational programs in biomedical informatics. It does so by addressing issues such as the processes related to comprehension of medical information, clinical problem-solving and decision-making, and the role of technology. This paper reviews these theories and methods from the cognitive and learning sciences and their role in addressing current and future needs in designing curricula, largely using illustrative examples drawn from medical education. The lessons of this past work are also applicable, however, to biomedical and health professional curricula in general, and to biomedical informatics training, in particular. We summarize empirical studies conducted over two decades on the role of memory, knowledge organization and reasoning as well as studies of problem-solving and decision-making in medical areas that inform curricular design. The results of this research contribute to the design of more informed curricula based on empirical findings about how people learn and think, and more specifically, how expertise is developed. Similarly, the study of practice can also help to shape theories of human performance, technology-based learning, and scientific and professional collaboration that extend beyond the domain of medicine. Just as biomedical science has revolutionized health care practice, research in the cognitive and learning sciences provides a scientific foundation for education in biomedicine, the health professions, and biomedical informatics.

Towards effective evaluation and reform in medical education: a cognitive and learning sciences perspective.

Health professions education is dealing with major transformations in light of the changing nature of the health care delivery system, including the use of technology for "just in time" delivery of care, evidence-based practice, personalized medical care and learning, as health professionals strive to integrate biomedical advances and clinical practice. This has forced the medical education community to reassess the current teaching and learning practices and more importantly, the evaluation of the medical education process. There have been recent advances in cognitive and learning sciences theories, some of which can inform medical educators about best teaching and learning practices and their impact on the evaluation process. An understanding of these theories provides a sound rationale for choosing specific instructional strategies and choosing evaluation measures that assess the curricular objectives. The review begins with an overview of evaluation and assessment in education, followed by an overview of major theories from the cognitive and learning sciences. Next, the role of cognitive and learning sciences theories in informing the process of medical education evaluation is discussed, including its impact on student learning, performance and professional competence, as well as recommendations for reform of medical curricula based on such theories. The paper continues with the elaboration of current trends in health sciences education, particularly medical education, and available evidence for the impact on student learning and performance as well as areas where more research is needed.

Development of a nutrition counselling care map for dyslipidemia.

PURPOSE: Care maps or clinical pathways for nutrition therapy of dyslipidemia could add to current practice guidelines, by providing templates for feasible and recommended diet counselling processes. A care map was therefore developed by engaging expert and generalist dietitians and external experts from across Canada in a multi-stage consensus process. METHODS: First, a qualitative study was undertaken with a convenience sample of 12 practitioners to identify possible diet care options, using hypothetical client scenarios and cognitive analysis. Second, these care options were rated for five case scenarios considered typical (overweight clients, with or without clinical cardiovascular disease and other comorbidities, potentially motivated to change, consuming high-fat diets, and facing various major barriers to eating behaviour change). The rating was conducted through a survey of participants. Highly appropriate, recommended, and feasible options for counselling were ranked through a two-round modified Delphi process, with teleconference discussions between rounds. RESULTS: Forty-nine professionals started the consensus process; 39 (80%) completed all aspects. Numerous care processes were appropriate for all clients, with additional focus on barriers for low-income clients, sodium intake for clients with hypertension, and smoking cessation in smokers. CONCLUSIONS: The resulting care map, "Dietitians' Quick Reference Guide for Clinical Nutrition Therapy for Overweight Clients with Dyslipidemia," provides a basis for current practice and new effectiveness studies.

Assessing health numeracy among community-dwelling older adults.

Quantitative information occupies a central role within health care decision making. Despite this, numeracy has attracted little research attention. Therefore, the purpose of this study was to (1) describe the health numeracy skill of a nonclinical, Canadian community-based senior population and (2) determine the relationship between health numeracy skill and prose health literacy, education, and math anxiety in this population. A convenience sample of 140 men and women, 50 + years, completed a questionnaire assessing demographic details, math anxiety, functional health literacy (Shortened Test of Functional Health Literacy for Adults STOFHLA), general context numeracy, and health context numeracy skills. Most participants had adequate functional health literacy (prose and numeracy) as measured by the STOFHLA, poorer general context numeracy skill, higher health context numeracy skill, and moderate math anxiety. Approximately 36% of the variation in general context numeracy scores and 26% of the variation in health context numeracy scores were explained by prose health literacy skill (STOFHLA), math anxiety, and attained education. This research offers an initial assessment of health numeracy skills as measured by three existing numeracy scales among a group of independently functioning older Canadian adults. This work highlights the need for clarification of the numeracy concept and refinement of health numeracy assessment instruments. Moreover, identifying patients' numeracy strengths and weaknesses will enable the development of focused numeracy interventions and may contribute to moving individuals further along the continuum of health literacy proficiency.

Shaping understanding of HIV through negotiation and conflict resolution during peer group discussion.

High-risk behavior in youths related to HIV transmission continues to occur despite large-scale efforts to disseminate information about safe sexual practices through education. Our study examined the relationships among knowledge, decision-making strategies, and risk assessment about HIV by youths during peer group focused discussions. Two focus groups with first-year college students were conducted, with a series of questions about risk for HIV transmission as prompts. All group interactions were recorded, transcribed and analyzed using methods of discourse analysis to characterize a detailed description of the interactions. The results indicated that youths negotiated their perspectives with the use of justification and elaboration to support alternative opinions and positions. They used concrete experiential examples to further explain and illustrate their positions, Opposing views or arguments met with requests for clarification and further negotiation. This cycle of clarification-negotiation shaped their understanding of HIV-related concepts. The use of strategies, such as justification of alternative positions and the use of examples as support for arguments to clarify and negotiate various perspectives, could be used as a tool for designing educational programs to improve understanding of health related issues, such as HIV transmission and prevention.

Knowledge integration and reasoning as a function of instruction in a hybrid medical curriculum.

This study investigates the effect of curricular change on knowledge integration and reasoning processes during problem-solving by medical students. The curricular change involved the introduction of problem-based, small group tutorials into a conventional health science curriculum (CC). Students at three levels of training were asked to provide diagnostic explanations of two clinical cases, both before (spontaneous) and after (primed) being exposed to basic science information relevant to the clinical problems. Data were analyzed using techniques of propositional and semantic analysis. Based on theories of instruction and cognition, we expected that the instructional changes would facilitate knowledge integration and influence the reasoning patterns of the students. The results show that students generated fewer inferences and used more information from the basic science text (text-based) to explain the clinical problems. However, they generated a greater number of elaborations during explanations using a mixture of data-driven and hypothesis-driven strategies. The spontaneous and primed problem-solving conditions produced more hypothesis-driven and data-driven strategies, respectively, as would be expected in a hybrid curriculum. We conclude that a) problem-based, small group tutorials facilitate integration of clinical and biomedical knowledge through the use of elaborations and hypothesis-driven strategies, and b) aspects of problem-based learning can be successfully integrated into traditional curricula.

Identifying reasoning strategies in medical decision making: a methodological guide.

Reasoning strategies are a key component in many medical tasks, including decision making, clinical problem solving, and understanding of medical texts. Identification of reasoning strategies used by clinicians may prove critical to the optimal design of decision support systems. This paper presents a formal method of cognitive-semantic analysis for the identification and characterization of reasoning strategies deployed in medical tasks and demonstrates its use through specific examples. Although semantic analysis was originally developed in the investigation of knowledge structures, it can also be applied to identify the reasoning and decision processes used by physicians and medical trainees in clinical tasks. Assumptions underlying the methods, as well as illustrations of their use in diagnostic explanation tasks, are presented. We discuss semantic analysis in the context of the current interests in developing medical ontologies and argue that a frame-based propositional analytic methodology can provide a systematic way of addressing the construction of such ontologies. Although the application of propositional analysis methods has some limitations, we show how such limitations are being addressed and present some examples of information tools that have been developed to ease, and make more systematic, the process of analysis.

Case-based medical informatics.

BACKGROUND: The "applied" nature distinguishes applied sciences from theoretical sciences. To emphasize this distinction, we begin with a general, meta-level overview of the scientific endeavor. We introduce the knowledge spectrum and four interconnected modalities of knowledge. In addition to the traditional differentiation between implicit and explicit knowledge we outline the concepts of general and individual knowledge. We connect general knowledge with the "frame problem," a fundamental issue of artificial intelligence, and individual knowledge with another important paradigm of artificial intelligence, case-based reasoning, a method of individual knowledge processing that aims at solving new problems based on the solutions to similar past problems. We outline the fundamental differences between Medical Informatics and theoretical sciences and propose that Medical Informatics research should advance individual knowledge processing (case-based reasoning) and that natural language processing research is an important step towards this goal that may have ethical implications for patient-centered health medicine. DISCUSSION: We focus on fundamental aspects of decision-making, which connect human expertise with individual knowledge processing. We continue with a knowledge spectrum perspective on biomedical knowledge and conclude that case-based reasoning is the paradigm that can advance towards personalized healthcare and that can enable the education of patients and providers. We center the discussion on formal methods of knowledge representation around the frame problem. We propose a context-dependent view on the notion of "meaning" and advocate the need for case-based reasoning research and natural language processing. In the context of memory based knowledge processing, pattern recognition, comparison and analogy-making, we conclude that while humans seem to naturally support the case-based reasoning paradigm (memory of past experiences of problem-solving and powerful case matching mechanisms), technical solutions are challenging.Finally, we discuss the major challenges for a technical solution: case record comprehensiveness, organization of information on similarity principles, development of pattern recognition and solving ethical issues. SUMMARY: Medical Informatics is an applied science that should be committed to advancing patient-centered medicine through individual knowledge processing. Case-based reasoning is the technical solution that enables a continuous individual knowledge processing and could be applied providing that challenges and ethical issues arising are addressed appropriately.

Relationship between small group problem-solving activity and lectures in health science curricula.

Components of problem-based education, such as small group teaching, are being implemented in diverse health curricula. Implementation, however, is often motivated by the intuitive appeal of many problem-based learning components, when what is needed is the detailed examination of how these components support students' integration of knowledge as well as continuity of their learning experiences. This study presents an investigation of the relationship between lecture and small group teaching (SGT) in a medical curriculum. Four problem-oriented SGT sessions representing diverse topics in the first-year curriculum and their corresponding lectures were videotaped and analyzed using techniques of concept mapping, where the broad concepts from the lectures were identified and matched to the case-specific concepts in the small group sessions. The results show that lectures function as an anchor for the students' discussion of issues relevant to clinical problem-solving and interventions in small group sessions. These discussions extended to contextual aspects of clinical practice that were not dealt with in the lectures, such as ethical/cultural issues around the treatment of patients. Furthermore, small group environments were found to promote discussions that allowed the integration of information from different sources and encompassed concepts across a number of disciplines. These results suggest that carefully designed small group sessions serve the purposes of 1) illustrating broader concepts in lectures to case-specific, clinically relevant problem-solving and 2) promoting knowledge integration from diverse sources of information. The implications of these results for learning and reasoning in health science curricula are discussed.

Readability of cancer information on the internet.

BACKGROUND: Literacy is considered an essential component of individuals' ability to increase control over their health. However, the majority of printed cancer information is written at readability levels of high school or higher and may be difficult to comprehend by people who are searching for medical information. Since low literacy is associated with poorer health and since a growing number of people are searching the Internet for health information, our research questions were twofold: (1) What is the readability level of popular Web sites on breast, colon, and prostate cancers? and (2) Does readability level differ as a function of the Web sites' organizational origin? METHODS: Breast, colon, and prostate cancer Web sites were selected for analysis by comparing the first 100 hits of 10 popular search engines. A total of 55 Web sites on breast (n = 20), colorectal (n = 18), and prostate (n = 17) cancers were included in the final analysis and assessed for readability using SMOG, Flesch-Kincaid (F-K), and Flesch Reading Ease (FRE) measures. RESULTS: The overall mean reading level of the cancer Web sites was Grade 13.7 using the SMOG formula and Grade 10.9 according to F-K. The mean FRE score was 41.6. The majority of Web sites (63.6%) were written at college level (Grade 13+) according to SMOG, especially those with a domain of ".com" and "org." Breast cancer sites were written at easier reading grade levels than sites on prostate cancer and colorectal cancer. Breast cancer sites also showed the largest increase in reading difficulty between opening and concluding paragraphs of text. CONCLUSIONS: Readability of cancer information on the Internet is at a college level. Individuals with basic literacy skills must be considered when posting cancer information on the Internet. Otherwise this information will remain inaccessible to a segment of the population who is at risk for cancer.

Patients' and physicians' understanding of health and biomedical concepts: relationship to the design of EMR systems.

OBJECTIVE: 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. DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.