Computer-assisted medical history taking prior to patient consultation in the outpatient care setting: a prospective pilot project

• Published in: BMC health services research 2024-12, Vol.24 (1), p.1616-12
• Main Authors: Hauber, Roman, Schirm, Maximilian, Lukas, Mirco, Reitelbach, Clemens, Brenig, Jonas, Breunig, Margret, Brenner, Susanne, Störk, Stefan, Puppe, Frank
• Format: Article
• Language: English
• Subjects: Adult; Aged; Ambulatory Care; Ambulatory medical care; Care and treatment; Clinical documentation; Digital health; Feasibility Studies; Female; Germany; Humans; Interoperability; Knowledge-based system; Knowledge-based systems; Male; Medical consultation; Medical history taking; Medical History Taking - methods; Medical research; Medicine; Medicine, Experimental; Methods; Middle Aged; Patient Satisfaction; Patients; Physician and patient; Pilot project; Pilot Projects; Practice; Prospective Studies; Referral and Consultation; Software; Technological anamnesis concept; Technology application; Workflow
• ISSN: 1472-6963; 1472-6963
• DOI: 10.1186/s12913-024-12043-3

Feeding patients' self-reported medical history into the diagnostic care process may accelerate workflows in clinical routine. We prospectively piloted a novel medical history documentation system in a German cardiological outpatient practice and evaluated its feasibility and perceived usefulness. Based on a generic software that allows to record structured information, a customized solution for the cooperating practice was developed and implemented. Prior to the consultation of the physician, the patient used a tablet that guided the user through a structured comprehensive workflow to document the medical history. The retrieved information was arranged by the software into a ready-to-use text format, presented to the physician in an editable form and added to her report. Three user-centered endpoints were explored: i) Appropriateness-measured by the duration of a patient interview; ii) Patient acceptance-assessed by three questions to patients; iii) Usefulness-operationalized by multiple ratings of the physician. A total of 2,513 patients were approached of which 2,415 provided complete histories. The system was assessed as appropriate for the practical workflow in terms of time and workflows. The patient-system interaction was rated favourably by patients including elderly ones. The system was regarded useful by the physician, reducing her daily workload by about one hour. Automated history-taking tools deployed before consultation could support physicians in obtaining patients' medical histories, thereby reducing professionals' perceived workload. The technical and methodological limitations of our study should be respected, calling for additional future evaluations.