For Patient History, Let The Computer Do The Work

December 18, 2014

Computer-generated patient histories are more thorough, organized, and useful than physician-written histories.

Computer-generated history of present illnesses (HPIs) are more effective at collecting information about patients than are HPIs written by physicians during usual care in gastrointestinal (GI) clinics, according to a study published in the American Journal of Gastroenterology.

Researchers from Cedars-Sinai Medical Center in Los Angeles, CA performed a cross-sectional study to compare the quality of computer-generated (Automated Evaluation of Gastrointestinal Symptoms [AEGIS]) versus physician-documented HPIs in outpatient adult GI clinics.

Seventy-five patients were identified for the study. The patients reported a variety of symptoms, including abdominal pain, heartburn, reflux, nausea, vomiting, constipation, and diarrhea. The physicians initially entered the patient history data into the electronic health record (typing or dictation). The patients then subsequently completed AEGIS on a website called My GI Health.

Forty-eight blinded physicians also participated in the study. Using five-point scales, they assessed HPI quality across six domains:

1. Overall impression

2. Thoroughness

3. Usefulness

4. Organization

5. Succinctness

6. Comprehensibility

The findings showed that the mean overall impression score for computer-generated HPIs was higher than physician HPIs (3.68 versus 2.80), even after adjusting for physician and visit type, location, mode of transcription, and demographics. Computer-generated HPIs were also judged more complete (3.70 versus 2.73), more useful (3.82 versus 3.04), better organized (3.66 versus 2.80), more succinct (3.55 versus 3.17, and more comprehensible (3.66 versus 2.97).

"The computer-generated narratives were of higher quality overall," lead author Christopher V. Almario, MD, gastroenterology fellow, Cedars-Sinai, said in a release.

The researchers said that computers offer a solution to the problem of doctors entering incomplete or inaccurate information into patients' records. They also noted that the technology also frees physicians to focus more on patients during office visits and to catch important bits of information and nonverbal cues that might otherwise be missed.