Le système de santé d'aujourd'hui fait appel à de nombreuses technologies de l'information nommées TIS (Technologies de l’Information en Santé). Celles-ci ont donné naissance à de nouvelles formes d’interaction médecin-patient et ont complexifié l'approche thérapeutique dite
« centrée sur le patient ». Les TIS promettent une plus grande efficacité et l’augmentation de la satisfaction des patients par le biais d’une meilleure compréhension de la maladie pour le patient. Or, elles peuvent également devenir des sources de conflit pour le professionnel de la santé, étant donné leur utilisation en dehors des rencontres cliniques ainsi que leur tendance à agir comme des barrières communicationnelles lors des consultations. Cette recherche vise a étudier les critères de design nécessaires à la conception d’un TIS pouvant améliorer la relation médecin-patient et donc, faciliter la communication et améliorer l’alliance thérapeutique. L’étude utilise une approche centrée sur l’utilisateur et vise donc à comprendre les besoins et les attentes des médecins et des patients. En étudiant les nouvelles approches en santé et les TIS, il a été possible de comprendre le contexte et les besoins des utilisateurs en terme de communication. Ces derniers sont primordiaux au processus dit centré sur l’utilisateur. Le faible taux de rétention du discours du médecin devient une barrière communicationnelle importante, tout comme le temps pressurisé. La recherche nous montre que l’ajout d’un outil virtuel de vulgarisation peut, à l’aide de média visuels (tel que des modélisations, des animations 3D et des dessins), grandement aider la relation médecin-patient. / Today’s medical system is using an increasing number of information technologies to help healthcare professionals in their daily practice. Commonly known as HIT (Health Information Technologies), they create new forms of doctor-patient interaction and complexify the therapeutic approach called “patient centered approach”. Their use promises to improve the efficiency of the healthcare system and the overall satisfaction of the patient by improving his understanding of his illness, yet they can also become communication barriers during a consultation and even a source of conflict when used outside a clinical context. This research project aims at studying the design criteria for a Health Information tool that can help improve the doctor-patient relationship. The study uses a user-centered approach and therefore, focuses on understanding the needs and expectations of both doctors and patients. The study of the theoretical and "on the field" therapeutic approach shows that the pressurized time of the consultation, the many communication barriers and the low level of information remembered by patients are problems that can be solved by a HIT. A virtual vulgarization tool that uses multimedia such as 3D animations, 3D models and drawings can considerably help the doctor-patient relationship.

Grâce à l’évolution de la technologie à travers le Web, la documentation relative à la santé est de plus en plus abondante et accessible à tous, plus particulièrement aux patients, qui ont ainsi accès à une panoplie d’informations sanitaires. Malheureusement, la grande disponibilité de l’information médicale ne garantit pas sa bonne compréhension par le public visé, en l’occurrence les non-experts. Notre projet de thèse a pour objectif la création d’une ressource de simplification de textes médicaux, à partir d’une analyse syntaxico-sémantique des verbes dans quatre corpus médicaux en français qui se distinguent de par le degré d’expertise de leurs auteurs et celui des publics cibles. La ressource conçue contient 230 patrons syntaxicosémantiques des verbes (appelés pss), alignés avec leurs équivalents non spécialisés. La méthode semi-automatique d’analyse des verbes appliquée pour atteindre notre objectif est basée sur quatre tâches fondamentales : l’annotation syntaxique des corpus, réalisée grâce à l’analyseur syntaxique Cordial (Laurent, Dominique et al, 2009) ; l’annotation sémantique des arguments des verbes, à partir des catégories sémantiques de la version française de la terminologie médicale Snomed Internationale (Côté, 1996) ; l’acquisition des patrons syntactico-sémantiqueset l’analyse contrastive du fonctionnement des verbes dans les différents corpus. Les patrons syntaxico-sémantiques des verbes acquis au terme de ce processus subissent une évaluation (par trois équipes d’experts en médecine) qui débouche sur la sélection des candidats constituant la nomenclature de la ressource de simplification. Les pss sont ensuite alignés avec leurs correspondants non spécialisés, cet alignement débouche sur le création de la ressource de simplification, qui représente le résultat principal de notre travail de thèse. Une évaluation du rendement du contenu de la ressource a été effectuée avec deux groupes d’évaluateurs : des linguistes et des non-linguistes. Les résultats montrent que la simplification des pss permet de faciliter la compréhension du sens du verbe en emploi spécialisé, surtout lorsque un certains paramètres sont réunis. / With the evolution of Web technology, healthcare documentation is becoming increasinglyabundant and accessible to all, especially to patients, who have access to a large amount ofhealth information. Unfortunately, the ease of access to medical information does not guaranteeits correct understanding by the intended audience, in this case non-experts. Our PhD work aimsat creating a resource for the simplification of medical texts, based on a syntactico-semanticanalysis of verbs in four French medical corpora, that are distinguished according to the levelof expertise of their authors and that of the target audiences. The resource created in thepresent thesis contains 230 syntactico-semantic patterns of verbs (called pss), aligned withtheir non-specialized equivalents. The semi-automatic method applied, for the analysis of verbs,in order to achieve our goal is based on four fundamental tasks : the syntactic annotation of thecorpora, carried out thanks to the Cordial parser (Laurent et al., 2009) ; the semantic annotationof verb arguments, based on semantic categories of the French version of a medical terminologyknown as Snomed International (Côté, 1996) ; the acquisition of syntactico-semantic patternsof verbs and the contrastive analysis of the verbs behaviors in the different corpora. Thepss, acquired at the end of this process, undergo an evaluation (by three teams of medicalexperts) which leads to the selection of candidates constituting the nomenclature of our textsimplification resource. These pss are then aligned with their non-specialized equivalents, thisalignment leads to the creation of the simplification resource, which is the main result of ourPhD study. The content of the resource was evaluated by two groups of people : linguists andnon-linguists. The results show that the simplification of pss makes it easier for non-expertsto understand the meaning of verbs used in a specialized way, especially when a certain set ofparameters is collected.

<p>This thesis analyse how life-histories are expressed and reformulated in connection to a life crisis of ill health. The study is based on ten interviews with people who in connection with ill health have made use of treatments within both orthodox medicine and complementary medicine and who have also developed various forms of self-treatment. The overall aim is, with a point of departure in the concepts health, healing and trust, to analyse narratives as a practice through which the respondents create identity and a life-context. The signifi cance of constructing the (auto)biography of the healing narrative – a form of narrative and performative act – runs as the main thread through the thesis. This act makes up the practice that is recurrently discussed in several of the thesis’ chapters and is synonymously termed the telling of healing narratives or or to narrate health and healing. The analysis of the narrative’s The analysis of the narrative’s healing main themes is mirrored in the order of the chapters. The study is broadly thematic and structured as a generalised healing process beginning with upheaval, continuing with crisis and social drama, and further to the endeavour of expressing values and judgements in a public context.</p><p>The interview themes of self-treatment and alternative treatment have occasioned the investigation into what an ethno-medical perspective can bring to analyses of people’s experiences of ill health in an everyday medical context. One of the points of having the concept ethno-medicine as a starting point is that every practice or narrative formation is ascribed with a potential for interpretation in its creation of knowledge. Another chapter deals with two themes of identity and life-history construction in the practice of healing narratives – the need for a chronology and reappraised perspectives on body, health and lifestyle. Healing narratives can be understood as a genre of life-historical narratives where life is often described as a linear course of events. A model by the anthropologist Victor Turner on the course and content of social drama is used as a comment to analyses of three respondents’ narratives in another chapter. A drama can be understood as a tragic course of events, based on an accident or an upsetting incident that roughly revolves around event/crisis, chaos and the striving for restoration. The concept of other journals is then used to make visible the everyday medical administrative practice and refers to the documentation used in the form of collected documents, written notes, and diaries. As an unexpected part of healing processes, the necessity of familiarising oneself with rules, laws and health insurance systems in order to be able to claim one’s rights is brought forward.</p><p>The social transformation process of various care practices in society makes up both a context and a commonly occurring theme in the narratives that the thesis is based upon. A modern health culture that gains strength from loosely composed social movements exerts infl uence on all levels of society. With an increased individual responsibility, the need grows to fi nd one’s own healing strategies and to create one’s own life-history in narratives that mirror this transformation in an everyday context. Healing narratives can be seen as a form of evaluation of health-care practices where experiences of treatment and notions of health and cure and healing are concretised.</p>

This thesis analyse how life-histories are expressed and reformulated in connection to a life crisis of ill health. The study is based on ten interviews with people who in connection with ill health have made use of treatments within both orthodox medicine and complementary medicine and who have also developed various forms of self-treatment. The overall aim is, with a point of departure in the concepts health, healing and trust, to analyse narratives as a practice through which the respondents create identity and a life-context. The signifi cance of constructing the (auto)biography of the healing narrative – a form of narrative and performative act – runs as the main thread through the thesis. This act makes up the practice that is recurrently discussed in several of the thesis’ chapters and is synonymously termed the telling of healing narratives or or to narrate health and healing. The analysis of the narrative’s The analysis of the narrative’s healing main themes is mirrored in the order of the chapters. The study is broadly thematic and structured as a generalised healing process beginning with upheaval, continuing with crisis and social drama, and further to the endeavour of expressing values and judgements in a public context. The interview themes of self-treatment and alternative treatment have occasioned the investigation into what an ethno-medical perspective can bring to analyses of people’s experiences of ill health in an everyday medical context. One of the points of having the concept ethno-medicine as a starting point is that every practice or narrative formation is ascribed with a potential for interpretation in its creation of knowledge. Another chapter deals with two themes of identity and life-history construction in the practice of healing narratives – the need for a chronology and reappraised perspectives on body, health and lifestyle. Healing narratives can be understood as a genre of life-historical narratives where life is often described as a linear course of events. A model by the anthropologist Victor Turner on the course and content of social drama is used as a comment to analyses of three respondents’ narratives in another chapter. A drama can be understood as a tragic course of events, based on an accident or an upsetting incident that roughly revolves around event/crisis, chaos and the striving for restoration. The concept of other journals is then used to make visible the everyday medical administrative practice and refers to the documentation used in the form of collected documents, written notes, and diaries. As an unexpected part of healing processes, the necessity of familiarising oneself with rules, laws and health insurance systems in order to be able to claim one’s rights is brought forward. The social transformation process of various care practices in society makes up both a context and a commonly occurring theme in the narratives that the thesis is based upon. A modern health culture that gains strength from loosely composed social movements exerts infl uence on all levels of society. With an increased individual responsibility, the need grows to fi nd one’s own healing strategies and to create one’s own life-history in narratives that mirror this transformation in an everyday context. Healing narratives can be seen as a form of evaluation of health-care practices where experiences of treatment and notions of health and cure and healing are concretised.

L’information des patients est devenue un enjeu de santé publique et une composante essentielle de la relation médecin patient. De nombreux auteurs s’accordent à dire que l’information écrite est un complément indispensable à l’obligation d’information orale car elle améliore la qualité des soins et l’adhérence du patient à sa prise en charge. Malgré l’existence de nombreuses Fiches d’Information Patient (FIP), le médecin a du mal à se les approprier. Elles sont souvent non validées, peu lisibles, difficiles à stocker, sans références, sources ni dates de rédaction. La première étape de notre travail a consisté à proposer une méthode pour élaborer des fiches d’information du patient (FIP) et à partir d’elle, 125 FIP concernant des motifs de consultation les plus fréquents en soins primaires. Une étude observationnelle réalisée dans 26 cabinets de médecine générale auprès de 350 patients, a montré d’une part que les patients sont demandeurs de FIP et qu’elles sont appréciées des patients. Et d’autre part, que la compréhension des maladies aiguës est plus limitée que celles des maladies chroniques ou situations de prescription chez les patients à faible niveau scolaire. Une étude interventionnelle randomisée en clusters réalisée dans 24 cabinets de médecine générale auprès de 400 patients, nous a permis de montrer que les FIP permettaient aux patients d’améliorer leur niveau de connaissances sur les pathologies et de modifier positivement leur comportements de santé, y compris pour les patients à faible niveau scolaire. Néanmoins, il n’était pas possible de comparer ces résultats à ceux de la littérature, les protocoles de recherche étant trop hétérogènes (critères de jugement spécifiques d’une situation clinique donnée).Pour surmonter cette difficulté, nous basant sur une « revue des revues » de la littérature, nous avons proposé un modèle théorique décrivant les modalités d’action des FIP au cours de la consultation, à partir duquel nous avons élaboré trois scores génériques utilisables pour tout type de consultation : un score de Communication Médecin Malade (CMM), un score de satisfaction et un score d’adhérence globale. Une fois les propriétés psychométriques de ces scores validés, nous avons étudié leurs déterminants. En situation aiguë, le seul déterminant de la CMM était la qualité de l’information reçu (quoi et que faire multipliant la probabilité d’une bonne communication par 11.9), les caractéristiques du patient n’influençant pas la CMM. L’adhérence globale est déterminée par le type de pathologie (paramètre inflexible) et par la qualité de la CMM. Enfin, la satisfaction, bien que tout autant liée à l’infrastructure, à l’équipe paramédicale et à l’équipe médicale, est également améliorée par une CMM de bonne qualité. En situation aiguë, la CMM est donc primordiale et impacte sur les indicateurs santé usuels que sont la satisfaction et l’adhérence des patients.Enfin, nous avons évalué avec ces nouveaux outils l’impact de 6 FIP sur la CMM, l’adhérence globale du patient et la satisfaction dans deux services d’urgences auprès de 324 patients. Cette étude interventionnelle avant-après nous a permis de montrer que les FIP améliorent: la CMM, la satisfaction vis-à-vis des professionnels de santé, le comportement des patients (qui respectent mieux les modalités de prises des médicaments et reconsultent moins dans les services d’urgences pour une même pathologie) et le comportement des médecins (qui prescrivent moins médicaments et davantage d’examens complémentaires). En situation aiguë, un outil simple pour améliorer la CMM est l’usage de FIP délivrée en complément de l’information orale.La CMM est un critère de jugement fondamental qu’il conviendra à l’avenir d’utiliser plus souvent, notamment pour évaluer les interventions thérapeutiques non pharmacologiques en plein essor, et pour lesquelles la communication est probablement un déterminant majeur de l’efficacité. / Patient information has become a public health issue and an essential component of Doctor-Patient communication (DPC). Many authors agree that written information is an indispensable complement to the obligatory oral information, since it improves the quality of care and the patient adherence. Despite the existence of numerous Patient Information Leaflets (PILs), physicians have difficulty appropriating them; they are often not validated, hard to read, difficult to store, without references, sources and dates of writing. The first step in our work was to propose a methodology for developing PILs and from there, design 125 PILs for the most common reasons for consultation in primary care. An observational study carried out in 26 general practice offices with 350 patients showed that patients appreciate PILs. On the other hand, the understanding of Acute Conditions (AC) is more limited than that of chronic diseases or prescription situations, particularly patients with a low school level. A cluster randomized interventional study performed in 24 general practice offices with 400 patients showed that PILs allowed patients to improve their knowledge about pathologies and modify their health behaviors positively, independently of their level of education. Nevertheless, the heterogeneity of the research protocols made it impossible to compare our results with those of the literature.To overcome this scientific hurdle and continue our work on the assessment of PILs, we performed a review of the literature on the subject, constructed a theoretical model describing the various effects of PILs and created three generic scales usable for evaluating the impact of PILs on any type of condition (scales of Doctor-Patient Communication, satisfaction and overall adherence). An observational study carried out in 2 Emergency Departments (ED) allowed us to validate the 3 scores, assess the psychometric properties and elucidate their determinants. In the context of AC, the only determinant of the DPC was the quality of the information received (both information "what to do" and "when to reconsult" have an adjusted Odds Ratio 11.9. Characteristics of the patient did not influence the DPC score. The overall adhesion is determined by the type of pathology (inflexible parameter) and by the quality of the DPC. Finally, although satisfaction was strongly associated with the hospital infrastructure and the attitude of the paramedical and medical staff, a high DPC score multiplied the probability of having a good satisfaction score. In a context of emergency consultations, the DPC is paramount and has an impact on the usual health indicators: satisfaction and adherence.Finally, a before-after intervention study conducted in two ED showed that PILs improve DPC, satisfaction with healthcare professionals, and adherence to medication regimens. PILs decrease the number of reconsultations for the same pathology, in particular return to the ED. They reduce the number of drug prescriptions given by the doctor in favor of complementary examinations and specialized advice. In a context of AC, a PIL given by the doctor improves DPC, the patient’s satisfaction with healthcare professionals and improves both the doctor’s and the patient’s behaviors.The DPC is a fundamental outcome that will need to be measured more frequently in the future, including in acute situations.

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