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Related Experiment Videos

Comparisons between written and computerised patient histories.

M J Quaak1, R F Westerman, J H van Bemmel

  • 1Department of Medical Informatics, Free University, Amsterdam, The Netherlands.

British Medical Journal (Clinical Research Ed.)
|July 18, 1987
PubMed
Summary
This summary is machine-generated.

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Computerized patient interviews capture more data and yield more diagnostic hypotheses than traditional medical records. However, doctors found traditional records better expressed main complaints, suggesting computer use complements, not replaces, doctor interviews.

Area of Science:

  • Medical Informatics
  • Clinical Data Management

Background:

  • Traditional patient histories rely on written medical records, which may omit crucial patient-reported data.
  • Assessing the efficacy of computerized patient interviews in capturing comprehensive patient information is essential for improving diagnostic accuracy.

Purpose of the Study:

  • To compare the completeness and diagnostic utility of computerized patient interviews (patient record) against traditional written medical records (medical record) and a computerized version of the medical record (transcribed record).

Main Methods:

  • Collected patient histories from 99 patients using three methods: computerized interview, written interview, and a transcribed computerized version of the written interview.
  • Analyzed patient complaints, diagnostic hypotheses, observer variations, and compared records against final diagnoses.

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Main Results:

  • Computerized patient interviews contained 40% more data than medical records, with two-thirds of patients feeling they could express more complaints.
  • Doctors found medical records better expressed main complaints (52%) vs. patient records (15%), but diagnostic certainty was higher with patient records (38%) vs. medical records (26%).
  • Patient records yielded 20% more diagnostic hypotheses, but agreement between records and final diagnoses was low (22-33%).

Conclusions:

  • Computerized history-taking is suitable for specific patients and can supplement, but not replace, the traditional oral interview with a doctor.
  • Integration of computerized tools can enhance data capture and diagnostic hypothesis generation in clinical settings.