Comparisons between written and computerised patient histories.

Abstract

Patient histories were obtained from 99 patients in three different ways: by a computerised patient interview (patient record), by the usual written interview (medical record), and by the transcribed record, which was a computerised version of the medical record. Patient complaints, diagnostic hypotheses, observer and record variations, and patients' and doctors' opinions were analysed for each record, and records were compared with the final diagnosis.About 40% of the data in the patient record were not present in the medical record. Two thirds of the patients said that they could express all or most of their complaints in the patient record. The doctors found that the medical record expressed the main complaints better (52%) than the patient record (15%) but that diagnostic hypotheses were more certain in the patient record (38%) than in .the medical one (26%). The number of diagnostic hypotheses in the patient record was about 20% higher than that in the medical record. Intraobserver agreement (51%) was better than interobserver agreement (32%), while the interrecord agreement varied from 25% (between the medical and patient records) to 35% (between the transcribed and patient records). One third of final diagnoses were seen in the medical

Handheld Computer-assisted Self-interviews: User Comfort Level and Preferences

“…This finding is consistent with previous studies that have found high levels of user comfort and satisfaction with CASI applications, in general, [17][18][19][20][21][22][23] and handheld computers in particular. At both study sites, more than 90% of participants reported they were comfortable or very comfortable with the computer.…”

“…13 They also can eliminate data-entry and editing errors, allow for automatic range checking on participant answers, and permit users to review and check their answers. [17][18][19][20][21][22][23] CASI offers many advantages over other methods of survey data collection. [17][18][19][20][21][22][23] CASI offers many advantages over other methods of survey data collection.…”

Development and significance of automated history‐taking software for clinical medicine, clinical research and basic medical science

“…Quaak et al [52] reported a similar view. Physicians who were not responsible for primary data collection were asked to compare the diagnostic value of information acquired by a computerized, general medicine history-taking program with information from physician-acquired histories [52,53]. Although the computerized histories were acknowledged to contain more clinical information, physician histories were deemed more valuable for making diagnoses.…”

“…There has been no significant physician 'buy-in' to the use of computerized history-taking programs [31,41] Physicians who were questioned about the value of these programs believed that differences between their and computer findings were falsepositive computer outputs or nonrelevant information [31,41]. Quaak et al [52] reported a similar view. Physicians who were not responsible for primary data collection were asked to compare the diagnostic value of information acquired by a computerized, general medicine history-taking program with information from physician-acquired histories [52,53].…”

Evaluation of voice-based data entry to an electronic health record system for dentistry

“…Further recommendations were approved in the AIM: CEN workshop on medical record in 1993 [5] and its follow-up, the EU: CEN workshop, in 1997 [6]. The benefits of computerizing medical records have been reported in the literature [7]. One of the immediate benefits is that important information can be made available to the health professionals through automated reminders and alerts.…”