Computerization of the Patient History -Patient Answers Compared with Medical Records

Summary

Computerized medical history taking, in which patients answer questions by using a terminal, is compared with the written medical record for a group of 99 patients in internal medicine. Patient complaints were analysed with respect to their frequency of occurrence for all important tracts, such as the respiratory, the gastro-intestinal and the uro-genital tracts. About 36% of over 3,200 patient answers were identical in the patient record and the written record, but a considerable percentage of complaints (56%), that were present in the patient record, were missing in the written record; the reverse was true for 4.5%. A computerized patient record appears to contain more extensive information about patient complaints, still to be interpreted by the experienced physician.

Eine computergerechte Anamnese, wobei die Patienten selbst Fragen unter Benutzung eines Bildschirms beantworten, wird verglichen mit dem niedergeschriebenen Arztbericht für eine Gruppe von 99 Patienten der inneren Medizin. Die Beschwerden der Patienten wurden analysiert auf ihre Vorkommenshäufigkeit in allen wichtigen Organsystemen wie den Luftwegen, dem Verdauungstrakt und dem Urogenitaltrakt. Etwa 36% von mehr als 3200 Patientenantworten waren mit dem niedergeschriebenen Bericht identisch; jedoch fehlte in den niedergeschriebenen Berichten ein erheblicher Prozentsatz von Beschwerden (56%), die in den Patientenantworten auftauchten. Das Umgekehrte war der Fall für 4,5%. Eine computergerechte Anamnese enthält offensichtlich ausführlichere Informationen über die Beschwerden der Patienten, die dann jedoch noch durch einen erfahrenen Arzt interpretiert werden müssen.

Key-Words

Medical Record - Automated Patient History - Problem-oriented Record - Internal Medicine

Schlüssel-Wörter

Arztbericht - computergerechte Anamnese - problemorientierte Niederschrift - innere Medizin

• REFERENCES

• 1 Barnett G. O. Costar, a computer-based medical information system for ambulatory care. Proc. IEEE 1979; 67: 1226-1237.
• 2 Card W. I, Lucas R. W. Computer interpretation in medical practice. Int. J. Man-machine Studies 1981; 4: 49-57.
• 3 Quaak M. J, Van der Voort P. J. G, Van Bemmel J. H. Fourth generation software for the automation of the patient history (to be published in Computer Methods and Programs in Biomedicine).
• 4 Quaak M. J, Westerman R. F, Schouten J. A, Van Bemmel J. H. Appraisal of computerized medical histories, comparisons between computerized and conventional records (accepted for publication in Computers and Biomedical Research).
• 5 Quaak M. J, Westerman R. F, Schouten J. A, Hasman A, Van Bemmel J. H. Patient appreciation of computerized medical records (to be published in Medical Informatics).
• 6 Simborg D. W, Chadwick M, Whiting-O’Keefe Q. E, Tolchin S. G, Kahn S. A, Bergan E. S. Local area networks and the hospital. Comput. biomed. Res 1983; 16: 274-259.
• 7 Slack W. V, Slack C. W. Patient computer dialogue. New Engl. J. Med 1972; 286: 1304-1309.
• 8 Trell E. Interactive computer program for self-distributed medical questionnaires: notes on technical implementation and use. Med. Inform 1983; 8: 139-143.
• 9 Van Bemmel J. H. Status and analysis of medical computing in The Netherlands. Med. Inform 1983; 8: 95-107.
• 10 Van Hemel O. J. S, Schutte F, Van Bemmel J. H, Chang A. M. Feed-back in an obstetric data base. In Anderson J. (Edit.) Medical Informatics Europe. Berlin – Heidelberg – New York: Springer; 1978: 783-796.
• 11 Warner H. R. A sequential approach to history taking and diagnosis. Comput. biomed. Res. J 1972; 218-227.
• 12 Westerhof H. P, Boon W. M, Cromme P. V. M, Van Bemmel J. H. ELIAS, Support of the Dutch General Practitioner. In: Advances in Medical Informatics. Berlin: Springer; 1986