Tuesday, February 1, 2011

Yes, that computer can take a better history than you

In medical school, a significant portion of the second year is typically devoted to learning how to take patient histories.  That's because most medical students will begin patient care duties as third-years, and good patient care is dependent on getting an accurate history from the patient.

Learning how to structure the interview, respond to your patient's emotions, and elicit all of the needed clinical information is a daunting task.  I remember feeling so lost and confused in my first few sessions; the attendings made it look so effortless, yet I was struggling to remember what questions to ask.

A few years of practice later, I'm confident that I'm a better history-taker now than I was in medical school.  It came to my attention, though, that no matter how skilled I got at history-taking, something could always beat me.

The computer.

Automated patient history programs have been around for several years.  The data regarding their accuracy and acceptability is simply staggering.  No matter how comfortable patients feel with their doctor, they are much more likely to tell a computer program about their sexual indiscretion or cocaine habit than they are to tell their doc - even when they know that the doc will be reviewing what they input into the program. (1)

Automated patient history programs can screen for depression and substance abuse, and they do it with better sensitivity than an office nurse or doctor. (1) They can ensure that medication lists, family histories, and social histories are up to date.  They can even collect a 10-point Review of Systems.

Automated patient history programs aren't just for the middle and higher echelons of the socio-economic ladder, either.  They've been used successfully even in offices serving disadvantaged, low SES patients. (2,3)

Imagine greeting your patient in the room, skimming the data they've entered, asking your clarifying questions, doing your exam, and then having extra time to spend with decision-making, counseling, motivational interviewing.  Imagine, too, that your patient's HPI, ROS, family & social histories, and medication reviews have been inputted directly into your Electronic Health Record (EHR).

These scenarios are already a reality at forward-thinking family medicine offices across the country.  Dr. John Bachman and Dr. Alan Wenner have widely presented on the benefits of the automated patient history program they use called Instant Medical History (IMH).  The IMH website has some cool videos of the program in action (http://www.medicalhistory.com/).

A lot of hoopla about EHR implementation - patient portals and e-prescribing and voice recognition software - continues to permeate the pages of medical journals and newspapers.  I just can't shake the feeling that a critical element of a complete EHR system is missing from the conversation.

Let's get the patient into the EHR; let's broadcast the benefits of automated patient history software.

(1) Bachman JW.  The patient-computer interview: a neglected tool that can aid the clinician. 
Mayo Clin Proc. 2003 Jan;78(1):67-78.
(2) Pierce B.  The use of instant medical history in a rural clinic. J Ark Med Soc. 2000 May;96(12):444-7.
(3) Dugaw JE Jr et al.  Will patients use a computer to give a medical history? J Fam Pract. 2000 Oct;49(10):921-3

I have no relationship with the makers of IMH and have received no reward, financial or otherwise, for mentioning this software product.

1 comment:

  1. The computer should also ask people where they've lived in the past as part of their history, in case they've been exposed to environmental hazards. It would be a pretty simple thing to get their address or even just the towns where they've lived and check them against health maps. There was an interesting article about this in the latest ArcUser magazine.