The patient-computer interview: a neglected tool that can aid the clinician

Alcohol use screening and case finding: screening tools, clinical clues, and making the diagnosis

This article presents an evidence-based approach to screening and case finding for alcohol use disorders in primary care. Problematic alcohol use by both adults and adolescents is considered. For clarity, this evidence-based presentation is divided into 6 sections: (1) epidemiology of alcohol use disorders, (2) associated health problems, (3) US Preventive Services Task Force screening recommendations, (4) screening/case finding instruments, (5) screening/case finding strategies, and (6) summary. This article reviews the state-of-the-art, evidence-based concepts and practices for screening and case finding for alcohol use disorders among adults and adolescents in primary care settings.

Test-retest reliability in a computer-based medical history

The authors developed a computer-based medical history for patients to take in their homes via the internet. The history consists of 232 'primary' questions asked of all patients, together with more than 6000 questions, explanations, and suggestions that are available for presentation as determined by a patient's responses. The purpose of this research was to measure the test-retest reliability of the 215 primary questions that have preformatted, mutually exclusive responses of 'Yes,' 'No,' 'Uncertain (Don't know, Maybe),' 'Don't understand,' and 'I'd rather not answer.' From randomly selected patients of doctors affiliated with Beth Israel Deaconess Medical Center in Boston, 48 patients took the history twice with intervals between sessions ranging from 1 to 35 days (mean 7 days; median 5 days). High levels of test-retest reliability were found for most of the questions, but as a result of this study the authors revised five questions. They recommend that structured medical history questions that will be asked of many patients be measured for test-retest reliability before they are put into widespread clinical practice.

Computerized history-taking as a tool to manage dyslipidemia

Background

Validated guidelines to manage low-density lipoprotein (LDL)-cholesterol are utilized inconsistently or not at all even though their application lowers the incidence of coronary events. New approaches are needed, therefore, to implement these guidelines in everyday practice.

Methods and results

We compared an automated method for applying The National Cholesterol Education Panel (NCEP) guidelines with results from routine care for managing LDL-cholesterol. The automated method comprised computerized history-taking and analysis of historical data without physician input. Results from routine care were determined for 213 unselected patients and compared with results from interviews of the same 213 patients by a computerized history-taking program. Data extracted from hospital charts showed that routine care typically did not collect sufficient information to stratify risk and assign treatment targets for LDL-cholesterol and that there were inconsistencies in identifying patients with normal or elevated levels of LDL-cholesterol in relation to risk. The computerized interview program outperformed routine care in collecting historical data relevant to stratifying risk, assigning treatment targets, and clarifying the presence of hypercholesterolemia relative to risk.

Conclusions

Computerized history-taking coupled with automated analysis of the clinical data can outperform routine medical care in applying NCEP guidelines for stratifying risk and identifying patients with hypercholesterolemia in relation to risk.

An exploratory study of patient attitudes towards symptom reporting in a primary care setting. Benefits for medical consultation and syndromic surveillance?

OBJECTIVES

The aim of this study was to investigate people's attitude towards providing symptom information electronically before a consultation. Specific areas investigated include a) attitudes and experiences with regards to acquisition of information related to symptoms, b) attitudes towards computer based communication of symptoms to the general practitioner and how they preferred to carry out such reporting, and c) attitudes towards storage, use and presentation of symptom-data in general, and particularly in a symptom based surveillance setting.

METHODS

Data was collected from 83 respondents by use of convenience sampling.

RESULTS

The respondents were familiar with using the Internet for health purposes, such as acquisition of information related to their symptoms prior to a consultation. The majority of respondents had a positive attitude towards providing information about their symptoms to the general practitioner's office as soon as possible after falling ill. Over half of the respondents preferred to use e-mail or a web-interface to perform this task. Eighty four percent were willing to have their symptom data stored in their EPR and 76 percent agreed that the general practitioner might access the symptoms together with the prevalence of matching diseases in order to assist the diagnostic process during the next consultation.

CONCLUSIONS

The results of this study support the applicability of electronically mediated pre-consultation systems both for improving primary care consultation and for use in symptom based surveillance, including real-time surveillance.

Pilot study of providing online care in a primary care setting

OBJECTIVE

To study the use of e-visits in a primary care setting.

PATIENTS AND METHODS

A pilot study of using the Internet for online care ("e-visits") was conducted in the Department of Family Medicine at Mayo Clinic in Rochester, MN. Patients in the department preregistered for the service, and then were able to use the online portal for consultations with their primary care physician. Use of the online portal was monitored and data were collected from November 1, 2007, through October 31, 2009.

RESULTS

During the 2-year period, 4282 patients were registered for the service. Patients made 2531 online visits, and billings were made for 1159 patients. E-visits were submitted primarily by women during working hours and involved 294 different conditions. Of the 2531 e-visits, 62 (2%) included uploaded photographs, and 411 (16%) replaced nonbillable telephone protocols with billable encounters. The e-visits made office visits unnecessary in 1012 cases (40%); in 324 cases (13%), the patient was asked to schedule an appointment for a face-to-face encounter.

CONCLUSION

Although limited in scope, to our knowledge this is the largest study of online visits in primary care using a structured history, allowing the patient to enter any problem, and billing the patient when appropriate. The extent of conditions possible for treatment by online care was far-ranging and was managed with a minimum of message exchanges by using structured histories. Processes previously given as a free service or by nurse triage and subject to malpractice (protocols) were now documented and billed.

Issues and questions to consider in implementing secure electronic patient-provider web portal communications systems

PURPOSE

Patients are increasingly interested in using Internet-based technologies to communicate with their providers, schedule clinic visits, request medication refills, and view their medical records electronically. However, healthcare organizations face significant challenges in providing such highly personal and sensitive communication in an effective and user-friendly manner.

METHODS

Based on the literature and our experience in providing a secure web-based patient-provider communication portal in primary care clinics, a framework was developed that identifies key issues and questions to consider in implementing secure electronic patient-provider communications systems.

RESULTS

The framework serves to categorize the many lessons learned from our implementation process and the specific issues and questions healthcare organizations need to consider in implementing such systems related to seven areas: strategic fit and priority; selection process & implementation team; integration into communications and workflows; HIPAA issues & clinic policies; systems implementation & training; marketing & enrollment; on-going performance monitoring.

CONCLUSION

The framework provides a useful guide for organizations looking to implement secure electronic patient-provider communication systems.

The role of health kiosks in 2009: literature and informant review

Kiosks can provide patients with access to health systems in public locations, but with increasing home Internet access their usefulness is questioned. A literature and informant review identified kiosks used for taking medical histories, health promotion, self assessment, consumer feedback, patient registration, patient access to records, and remote consultations. Sited correctly with good interfaces, kiosks can be used by all demographics but many ‘projects’ have failed to become routine practice. A role remains for: (a) integrated kiosks as part of patient ‘flow’, (b) opportunistic kiosks to catch people’s attention. Both require clear ‘ownership’ to succeed.

Underutilization of information and knowledge in everyday medical practice: evaluation of a computer-based solution

BACKGROUND

The medical history is acknowledged as the sine qua non for quality medical care because recognizing problems is pre-requisite for managing them. Medical histories typically are incomplete and inaccurate, however. We show here that computers are a solution to this issue of information gathering about patients. Computers can be programmed to acquire more complete medical histories with greater detail across a range of acute and chronic issues than physician histories.

METHODS

Histories were acquired by physicians in the usual way and by a computer program interacting directly with patients. Decision-making of what medical issues were queried by computer were made internally by the software, including determination of the chief complaint. The selection of patients was from admissions to the Robert-Bosch-Hospital, Stuttgart, Germany by convenience sampling. Physician-acquired and computer-acquired histories were compared on a patient-by-patient basis for 45 patients.

RESULTS

The computer histories reported 160 problems not recorded in physician histories or slightly more than 3.5 problems per patient. However, physicians but not the computer reported 13 problems. The data show that computer histories reported problems across a range of organ systems, that the problems detected by computer but not physician histories were both acute and chronic and that the computer histories detected a significant number of issues important for preventing further morbidity.

CONCLUSION

A combination of physician and computer-acquired histories, in non-emergent situations, with the latter available to the physician at the time he or she sees the patient, is a far superior method for collecting historical data than the physician interview alone.

A research agenda for personal health records (PHRs)

Patients, policymakers, providers, payers, employers, and others have increasing interest in using personal health records (PHRs) to improve healthcare costs, quality, and efficiency. While organizations now invest millions of dollars in PHRs, the best PHR architectures, value propositions, and descriptions are not universally agreed upon. Despite widespread interest and activity, little PHR research has been done to date, and targeted research investment in PHRs appears inadequate. The authors reviewed the existing PHR specific literature (100 articles) and divided the articles into seven categories, of which four in particular--evaluation of PHR functions, adoption and attitudes of healthcare providers and patients towards PHRs, PHR related privacy and security, and PHR architecture--present important research opportunities. We also briefly discuss other research related to PHRs, PHR research funding sources, and PHR business models. We believe that additional PHR research can increase the likelihood that future PHR system deployments will beneficially impact healthcare costs, quality, and efficiency.

Safety of prescribing PDE-5 inhibitors via e-medicine vs traditional medicine

OBJECTIVE

To determine the safety of a US-based, state-regulated Internet system vs a multispecialty primary care system for prescribing phosphodiesterase type 5 (PDE-5) inhibitors for erectile dysfunction.

PATIENTS AND METHODS

From January 1, 2001, through December 31, 2005, 500 e-medicine clients (mean+/-SD age, 47+/-11 years; hypertension, 60%; type 2 diabetes mellitus, 2%; mean+/-SD number of medications, 0.4+/-0.8) vs 500 traditional medicine patients (mean+/-SD age, 57+/-12 years; hypertension, 50%; type 2 diabetes mellitus, 23%; mean+/-SD number of medications, 5.1+/-3.1) with erectile dysfunction symptoms were assessed. Noninferiority safety was assessed in this retrospective, cross-sectional study with stratified random sampling by identification of prescribing in the presence of clinically important PDE-5 inhibitor drug interactions with or without high-risk cardiovascular disease, by asking about diagnostic symptoms specific to erectile dysfunction, and by determining frequency of patient counseling.

RESULTS

Noninferiority of the e-medicine system was shown for the 6 safety end points, relative to a traditional medicine system. Numbers of inappropriate prescriptions, after correction for disease and medication covariates, did not differ between systems. Medication counseling showed superiority of the e-medicine system. Standard diagnostic questions were required for e-medicine prescribing but were infrequently asked in traditional medicine.

CONCLUSION

Safety in prescribing PDE-5 inhibitors for erectile dysfunction was similar between a US-based, state-regulated Internet prescribing system and a multispecialty primary care system.

Patient difficulty using tablet computers to screen in primary care

BACKGROUND

Patient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care.

OBJECTIVE

The aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care.

DESIGN

All patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire.

PATIENTS

Ten thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006.

MEASUREMENTS

We calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer.

RESULTS

The majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05-1.05)]; Asian race (OR 2.3, 95% CI 1.8-2.9); African American race (OR 1.4, 95% CI 1.2-1.6); less than a high school education (OR 3.0, 95% CI 2.6-3.4); and the presence of comorbid medical conditions (1-2: OR 1.3, 95% CI 1.2-1.5; > or =3: OR 1.7 95% CI 1.5-2.1).

CONCLUSIONS

The majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups.

Screen positive rates among six family history screening protocols for breast/ovarian cancer in four cohorts of women

It has been estimated that approximately 2% of the general population has a family history that is indicative of hereditary breast/ovarian cancer. We aim to further document the proportions of women identified by several protocols as having a positive family history of breast/ovarian cancer, as a prelude to offering genetic counseling and BRCA1/2 mutation testing. This is a critical component of the evidence base needed when considering implementation of family history screening in primary care. We apply six separate family history screening protocols for breast/ovarian cancer to four cohorts of women, 21 to 55 years of age, for whom self-reported personal, and first and second degree family histories of breast/ovarian cancer have been obtained. We analyzed family history for 3,073 women in the four cohorts. The screen positive rates among the protocols vary widely both within and among the cohorts. In Cohort 4, the screen positive rate ranges between 6.9% to 20.8%, depending on the protocol. Applying one of the protocols to the four cohorts yields screen positive rates between 5.0% and 16.7%. The proportion of women that is screen positive on all six protocols (or three, if Ashkenazi Jewish) ranges from 1.9% to 4.0%. Used alone, none of the recommended family history protocols yields an acceptable screen positive rate. A more acceptable 2% to 4% screen positive rate can be expected when all six protocols agree.

Applying quality-of-life data formally and systematically into clinical practice

The systematic integration of quality-of-life (QOL) assessment into the clinical setting, although deemed important, infrequently occurs. Barriers include the need for a practical approach perceived as useful and efficient by patients and clinicians and the inability of clinicians to readily identify the value of integrating QOL assessments into the clinical setting. We discuss the use of QOL data in patient care and review approaches used to integrate QOL assessment into the clinical setting. Additionally, we highlight select QOL measures that have been successfully applied in the clinical setting. These measures have been shown to identify key QOL issues, improve patient-clinician communications, and improve and enhance patient care. However, the work done to date requires continued development. Continued research is needed that provides information about benefits and addresses limitations of current approaches.

Development of a Smiling Touchscreen multimedia program for HRQoL assessment in subjects with varying levels of literacy

OBJECTIVE

As low literacy affects the assessment of health-related quality of life (HRQoL) in several ways (e.g., subject eligibility and cost of administration), better approaches to HRQoL assessment in subjects with varying literacy levels are needed.

METHODS

We developed a multimedia touchscreen program (the Smiling Touchscreen, ST) to administer HRQoL instruments to subjects with varying levels of Chinese language and computer literacy, using an iterative process where patients' input on design, clarity of instructions, and user-friendliness were repeatedly gathered and incorporated in development. The ST thus has several user-friendly features for low-literacy subjects (e.g., presentation of individual items using visual and auditory stimuli, voice-text synchronization, and visual analog scale with a touch and drag function), which we evaluated using qualitative and quantitative methods.

RESULTS

The ST was well accepted by subjects (n = 66, 76% female, median [interquartile] age: 49.0 [40.0, 56.0]) with high (n = 43) or low (n = 23) literacy, 98% of whom found it easy or very easy to use, and 85% found the voice-text synchronization feature useful. In low-literacy subjects without computer experience (30%), none reported any difficulties using the ST. The median (interquartile) time spent to complete the ST (four Instruction and Practice screens, 24 questions, one visual analog scale) for high- and low-literacy groups was 13.9 (9.6, 23.9) and 23.2 (15.8, 26.5) minutes, respectively. Among subjects expressing a preference (n = 47), 21 (47%) favored the ST over interviewer- or self-administration.

CONCLUSION

The ST is well accepted by subjects with varying literacy levels, including those without computer experience. It is thus a promising new approach for HRQoL assessment among subjects with varying literacy levels.

Development of an Internet-based real-time system for monitoring pharmacological interventions in children with neurodevelopmental and neuropsychiatric disorders

Few children have a 'pure' diagnosis of neuropsychiatric disorders such as attention deficit hyperactivity disorder or autism. Most have complex, overlapping symptoms, and it is often these associated and common comorbidities that cause as much, if not more impairments, than the core symptoms. Prescribing decisions are therefore complex and made on the basis of eliciting a range of agreed 'target symptoms'. At present, however, there are no agreed systems that allow monitoring of all areas of potential change, and few services are able to monitor symptoms, side effects, impact on family life and individual children's quality of life systematically. At best many clinics use a plethora of paper-based standardized questionnaires, based on individual diagnoses. This article describes the development of a novel biomedical informatics system that has been designed to allow parents, professionals and children to use a web-based, real-time symptom monitoring system to enable more effective treatments, better pathways of shared care, and more equitable and efficient service delivery for this group of vulnerable children.

Neural Networks for Ischemic Stroke

BACKGROUND

To have uniform criteria for evaluating populations for prevalence of transient ischemic attack (TIA)/stroke, validated instruments are necessary for objective assessment and classification.

METHODS

Patient responses compatible with symptoms of TIA or ischemic stroke, obtained from participants in a substudy of the Asymptomatic Carotid Atherosclerosis Study, were used to program a neural network for each symptom. Models were designed for rapid classification into 1 of 7 outputs: no event, TIA, or stroke (in left carotid, right carotid, or vertebrobasilar). The networks were then tested by comparing decisions with a validated questionnaire used to access an independent data set of 381 patients.

RESULTS

There were 144 patients who reported sudden speech change, 89 with sudden vision loss, 67 with double vision, 189 with sudden numbness, 223 with episodic dizziness, and 108 with paralysis, for a total of 820 reported symptoms among the 381 patients tested. For each category, an equal number of individuals reporting "No" to these phenomena were randomly selected and analyzed. Neural network classification correlated with the diagnoses made by specially trained stroke clinicians (e.g., all who responded "No" were correctly classified as having no neurologic event). Ten symptomatic patients were misclassified, with the most common reason being incomplete data. After adjustment of the network logic, these misclassifications did not recur.

CONCLUSION

Computer networks can be trained to produce a rapid and accurate classification of TIA or stroke by vascular distribution, enabling screening of populations for assessment of their incidence and prevalence.

Dial "T" for Testing: Technological Flexibility in Neuropsychological Assessment

Computer-automated neuropsychological testing can be conducted over the telephone via interactive voice response (IVR) technology by adapting cognitive measures traditionally administered by a clinician or in paper-and-pencil formats. By utilizing automated telephone interviews in neuropsychological research, time and money can be saved, and patients can be assessed remotely. This paper reviews the use of IVR to assess neuropsychological functioning in six studies that examined alcohol impairment of mental and physical functioning, cognitive and psychomotor recovery after surgery, and impairment resulting from central nervous system disease. Future directions for expanding application of cognitive performance assessment via IVR are discussed.

Computer interviewing in urogynaecology: concept, development and psychometric testing of an electronic pelvic floor assessment questionnaire in primary and secondary care

OBJECTIVE

To develop and evaluate a Web-based, electronic pelvic floor symptoms assessment questionnaire (e-PAQ)1 for women.

DESIGN

A cross-sectional study in primary and secondary care.

SETTING

Two general practices, two community health clinics and a secondary care urogynaecology clinic.

SAMPLE

A total of 432 women (204 in primary care and 228 in secondary care) were recruited between June 2003 and January 2004.

METHODS

The e-PAQ was located on a workstation (computer, touchscreen and printer). Women completed the e-PAQ prior to their appointment. Untreated women in primary care were asked to return seven days later to complete the e-PAQ a second time (test-retest).

MAIN OUTCOME MEASURES

Factor analysis, reliability, validity, patient satisfaction, completion times and system costs.

RESULTS

In secondary care, factor analysis identified 14 domains within the four dimensions (urinary, bowel, vaginal and sexual symptoms) with internal consistency (Cronbach's alpha)>or=0.7 in 11 of these. In primary care, alpha values were all>or=0.7 and test-retest analysis found acceptable intraclass correlations of 0.50-0.95 (P<0.001) for all domains. A measure of face validity and utility was gained using a nine-item questionnaire, which yielded strongly positive patient views on relevance and acceptability.

CONCLUSIONS

The e-PAQ offers a user-friendly clinical tool, which provides valid and reliable data. The system offers comprehensive symptoms and quality of life evaluation and may enhance the clinical episode as well as the quality of care for women with pelvic floor disorders.

Is a computer questionnaire of childhood asthma acceptable in general practice?

OBJECTIVES

To determine whether a previously-validated touch screen computer program of symptoms and management of childhood asthma is acceptable to parents who accompany their children to consult a GP, and to examine whether any parent characteristics are associated with acceptability.

METHODS

Conducted in general practice in Newcastle, NSW, Australia. A cross sectional pen and paper survey was given to parents of children consulting a GP after completing the computer questionnaire on childhood asthma in the waiting room. Measurements were frequencies of Likert scale responses to statements concerning the computer questionnaire, compared with demographic and personal characteristics.

RESULTS

High levels of acceptability of the asthma computer questionnaire were reported by the 198 respondents, with most being willing to do the same program once or twice a year (87%), or to do similar programs on other topics (91%). Most respondents (81%) agreed that the computer program was enjoyable, and very few (8%) would have preferred to answer the asthma questions by pen and paper rather than by computer. Two or more children accompanying the parent was the characteristic most associated with less positive responses.

CONCLUSIONS

Overall the high acceptability of this questionnaire suggests that this computerised format is an appropriate method of screening children for asthma and determining their current management. As a large component of underdiagnosis of asthma is lack of reporting to the doctor, this valid and acceptable diagnostic aid has the potential to improve detection of unreported asthma, and also to identify high-risk individuals.

Parents as partners in obtaining the medication history

OBJECTIVE

Patient-centered information management may overcome barriers that impede high-quality, safe care in the emergency department (ED). The utility of parents' report of medication data via a multimedia, touch screen interface, the asthma kiosk, was investigated. Our specific aims were (1) to estimate the validity of parents' electronically entered medication history for asthma and (2) to compare the parents' kiosk entries regarding medications to the documentation of ED physicians and nurses.

METHODS

We enrolled a cohort of parents to use the asthma kiosk and tested the validity of this communication channel for medication data specific to pediatric asthma. Parents' data provided via the kiosk during the ED encounter and the documentation of ED nurses and physicians were compared with a telephone-based interview with the parent after discharge that reviewed all asthma-specific medications physically present in the home. Treating clinicians in the ED were blinded to the parents' kiosk entries.

RESULTS

Sixty-six parents were enrolled and 49 of 66 (74.2%) completed the gold standard interview. When analyzed at the level of individual medications, the validity of parental report was 81% for medication name, 79% for route of delivery, 66% for the form of the medication, and 60% for dose. Parents' report improved on the validity of documentation by physicians across all medication details save for medication name. Parents' report was more valid than nursing documentation at triage for all medication details.

CONCLUSION

Parents can provide an independent source of medication data that improves on current documentation for key variables that impact quality and safety in emergency asthma care.

Exploring patient reactions to pen-tablet computers: a report from CaReNet

PURPOSE

We wanted to study patient receptivity to using pen-tablet computers for collecting data in a practice-based research network.

METHODS

We analyzed exit interviews and field notes collected by trained research assistants as part of a larger Colorado Research Network (CaReNet) study comparing pen-tablet and paper-pencil methods to collect data for the Primary Care Network Survey (PRINS).

RESULTS

A total of 168 patients completed a patient exit interview after completion of the pen-tablet-based survey instrument. Analyses of these brief interviews and field notes indicated that patients had favorable reactions to using pen-tablet computers. The most common barriers were related to glitches in the technology; the voice recognition software was the most problematic, with patients (as well as clinicians) finding this feature to be frustrating.

CONCLUSIONS

Patients were able and willing to use pen-tablet computers for completing forms within busy primary care offices. Increasing patient involvement in practice-based research may be even more practicable through the use of this novel technology, which can allow patient-directed data collection at a single point in time as well as longitudinally.