The road to a practical patient computer interview... description of a long experience...

by Edmund Messina MD

The problem is, we have limited amounts of time to interact with our patients...shortcuts are taken and data is missed.

In medicine, the errors of omission are often worse than the errors of comission. A physician wants to do a good job but pressures placed upon these physicians through insurance companies, employers and other sources, cause shortcuts to be taken.

The patient is not always aware of what facts may be relevant and unless we skillfully and patiently probe for specific information, as well as screening information, early detection of many diseases can be missed.

We commonly consider two types of patient information gathering; one is the acquisition of structured information from structured questions. The other is free conversational or "open-ended" questioning.

Clinicians have tried to gather structured information through paper-based checklists, administered by the patients themselves or through an assistant. A common problem is the lack of completeness or the inability of the patient to understand the terminology. Certainly, paper-based systems are unable to probe deeper into positive responses and cannot reveal inconsistencies. In addition, we overestimate the literacy as well as health literacy of many patients.

In recent decades, electronic methods have evolved which allow patient interrogation through the use of computers. My group has been developing and using such methods since the mid-1980s, and our methods have become more sophisticated over time.

The early automated programs worked better than simple paper questionnaires but they were flawed because of the simplicity of the questions and the simple branching. This is still true with most commercial EMR programs, especially when the questions are being asked by unskilled personnel, using primitive templates.

As a clinician and teacher, over the years, I became very interested in the process of asking questions. It became very apparent to me that an expert system was needed. My colleagues and I subsequently developed the FloBase® language for the purpose of simulating expert interrogation. With such an artificial intelligence system, questions could be asked according to specific rules, as developed by clinical experts. The program selects questions based upon accumulated responses, patient demographics and existing symptoms. The program forms hypotheses to drive lines of inquiry, like a 3-dimensional algorithm, and it systematically pursues lines of reason or backtracks itself when it reaches a blind alley.

Our next step was to develop a more personal interaction between patient and computer. A strength of the computer-assisted interview is the patient's perception of anonymity and the absence of any judgemental cues, since there is no live interviewer. A weakness was the impersonal text interface.

Over the years, we found it very useful for the patient to interact with a human face who is able to delve more deeply into specific sensitive areas. In addition, when the patient expresses difficulty understanding a question, the "video nurse" can clarify the question and ask it in different terms, to elicit a more accurate response from the patient. Some people are more likely to understand auditory than text questions.

It is important to identify inconsistencies in patient responses and to clarify them. For example, a patient may tell us that they are not sleepy but later admit to consuming large amounts of caffeine because of sleepiness. In this situation, the system asks the patient to clarify the inconsistency and stores the responses accordingly.

In this way, an intelligent history can be acquired which gathers key information and activates important "red flags" for the clinician. This is a rules-based system and the rules are made by experts. In order to express this information in a meaningful manner, we then found it necessary to expand the FloBase language to also generate intelligent reports. These rules allow the program to better organize and display the data in a clinically meaningful manner, not like an unthinking computer printout.

Our system can apply another set of rules to the data which has been acquired. For example, a patient might describe chest pressure and elsewhere in the review of systems might mention hoarseness and in another section they might report insomnia. Although each item might be reported within each of the respective sections of the Review of Systems, they may also be combined in a discussion which combines chest discomfort, insomnia and heartburn, presenting it in such a way that GERD needs to be considered. The same is true for shortness of breath which may be correlated with cardiac symptoms in the review of systems but also be correlated with respiratory symptoms or anxiety in other sections.

Such a rules-based system can be applied to existing guidelines which lead to specific diagnoses, such as those found in sources such as the DSM-V, for example.

A further extension of our automated history is to ask pertinent and relevant questions across subsequent visits. The data points which are acquired in each patient encounter with the program, such as symptoms or diagnoses, can be followed as a thread from visit to visit. Continuity is another dimension which improves quality of care.





The automated return visit history allows symptoms to be followed over time, especially in situations where quantitation is possible. For example, the history quantitates the number of cigarettes, the BMI, a drowsiness scale, a depression scale and other measurable symptoms, and trends can be pointed out to the patient and to the clinician. Correlations between increasing symptoms of depression and increasing BMI or ethanol intake may then become obvious.

An excellent review was written years ago by Dr. John W. Bachman in the Mayo Clinic proceedings (The Patient-Computer Interview: A Neglected Tool That Can Aid the Clinician, JOHN W. BACHMAN, MD, Mayo Clin Proc. 2003;78:67-78).

Dr. Bachman pointed out that traditional history taking is often incomplete and time-consuming for collection of information and also for documenting it.

Over the years, I've discovered that some patients are quite inaccurate with paper questionnaires because of their own health literacy or their actual literacy or understanding of the English language. In our own experience, many of these deficiencies can be compensated through the use of interactive video.

Dr. Bachman's article clearly illustrates the comparison between the different history taking techniques, showing the obvious advantages of interactive computer histories.

There are many problems with conventional paper questionnaires and "flat" questionnaires in many commercial EMR programs:

1) Questionnaires are not complete or exhaustive, for obvious reasons. They also may contain irrelevant questions, such as asking males about their menses.

2) Patients have a tendency to skip quickly through lists of questions, sometimes drawing a line through the entire "no" column.

3) Updating and maintaining paper questionnaires is very impractical.

4) Paper questionnaires are too plentiful and primary care physicians are overwhelmed with stacks of questionnaires which deal with various issues, risk factors, diagnoses, etc.

5) Most physicians do not bother to use questionnaires because they're impractical, even for a first encounter history.

6) Simple questionnaires do not clarify symptoms or resolve inconsistencies

By comparison, automated interactive computerized histories are extremely well structured, are self--explanatory and self-clarifying, and serve as excellent documentation for the medical record.

Arbor Medicus histories save physician time because the patient can answer questions by themselves or, in special-needs situations, with an assistant or family member, on their own time, unhurried. Data points identified in the patient's history, especially where inconsistencies arise, can serve as triggers for future patient education.

It is been shown that computerized histories can document more relevant information than a conventional physician interview. Although a significant time commitment is required on the part of the patient, the patient interface with the Arbor Medicus system can be broken down into multiple sessions... they can log in as often as they need to, to prepare for their medical visit.

Since Internet connections are readily available for personal computers, tablets and smart phones, patients can access this automated system from home, public libraries or in designated rooms in the clinic.

In addition to the empowerment the patient will experience by clearly expressing their problems, the automated history can also provide guidance or "speaking points" to better prepare the patient for their next medical visit. The patient history can be physically or electronically pasted into the medical record.

The accuracy of the patient computer interview is further enhanced by its nonjudgmental properties. The video nurse is nonthreatening and sympathetic. She reveals no disapproving facial expressions nor does she appear to be morally judgmental.

The interactive video componant breaks down barriers caused by culture, language and literacy.

Today's physician need not feel threatened by artificial intelligence computerized interviews. So far, at least, computers are not capable of detecting nonverbal behaviors from the patient being interviewed, so we physicians are still not obsolete.

Although the computer is quite impersonal, the patient interacting with the video, will have a warmer experience and, of course, understand that this is simply data gathering and does not take the place of a face-to-face interview with a health professional.

The actual interview of the patient, following computerized data acquisition, is much more personalized because the structured questioning is out of the way. The physician is better able to use open-ended questions or pursue deeper inquiry about areas that were exposed by the expert system interview.

Electronic history taking does not replace a physician but it is a valuable tool that can save considerable time.

Edmund Messina MD, FAHS




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