Computerized history-taking improves data quality for clinical decision-making-Comparison of EHR and computer-acquired history data in patients with chest pain. 2021

David Zakim, and Helge Brandberg, and Sami El Amrani, and Andreas Hultgren, and Natalia Stathakarou, and Sokratis Nifakos, and Thomas Kahan, and Jonas Spaak, and Sabine Koch, and Carl Johan Sundberg
Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Sweden.

Patients' medical histories are the salient dataset for diagnosis. Prior work shows consistently, however, that medical history-taking by physicians generally is incomplete and not accurate. Such findings suggest that methods to improve the completeness and accuracy of medical history data could have clinical value. We address this issue with expert system software to enable automated history-taking by computers interacting directly with patients, i.e. computerized history-taking (CHT). Here we compare the completeness and accuracy of medical history data collected and recorded by physicians in electronic health records (EHR) with data collected by CHT for patients presenting to an emergency room with acute chest pain. Physician history-taking and CHT occurred at the same ED visit for all patients. CHT almost always preceded examination by a physician. Data fields analyzed were relevant to the differential diagnosis of chest pain and comprised information obtainable only by interviewing patients. Measures of data quality were completeness and consistency of negative and positive findings in EHR as compared with CHT datasets. Data significant for the differential of chest pain was missing randomly in all EHRs across all data items analyzed so that the dimensionality of EHR data was limited. CHT files were near complete for all data elements reviewed. Separate from the incompleteness of EHR data, there were frequent factual inconsistencies between EHR and CHT data across all data elements. EHR data did not contain representations of symptoms that were consistent with those reported by patients during CHT. Trial registration: This study is registered at https://www.clinicaltrials.gov (unique identifier: NCT03439449).

UI MeSH Term Description Entries
D008297 Male Males
D008487 Medical History Taking Acquiring information from a patient on past medical conditions and treatments. Medical History, Previous,Past Medical History, Family,Previous Medical History,Family Health History,Family History, Health,Family History, Medical,Family Medical History,History Taking, Medical,Family Health Histories,Family Medical Histories,Health Family Histories,Health Family History,Health History, Family,History, Previous Medical,Medical Family Histories,Medical Family History,Medical Histories, Previous,Medical History, Family,Previous Medical Histories
D008875 Middle Aged An adult aged 45 - 64 years. Middle Age
D002637 Chest Pain Pressure, burning, or numbness in the chest. Precordial Catch,Precordial Catch Syndrome,Texidor's Twinge,Chest Pains,Pain, Chest,Pains, Chest,Syndrome, Precordial Catch,Texidor Twinge
D003658 Decision Making, Computer-Assisted Use of an interactive computer system designed to assist the physician or other health professional in choosing between certain relationships or variables for the purpose of making a diagnostic or therapeutic decision. Computer-Assisted Decision Making,Medical Decision Making, Computer-Assisted,Computer Assisted Decision Making,Decision Making, Computer Assisted,Medical Decision Making, Computer Assisted
D004632 Emergency Medical Services Services specifically designed, staffed, and equipped for the emergency care of patients. Emergency Care,Emergency Health Services,Emergicenters,Prehospital Emergency Care,Emergency Care, Prehospital,Emergency Services, Medical,Medical Services, Emergency,Services, Emergency Medical,Emergency Health Service,Emergency Medical Service,Emergency Service, Medical,Emergicenter,Health Service, Emergency,Health Services, Emergency,Medical Emergency Service,Medical Emergency Services,Medical Service, Emergency,Service, Emergency Health,Service, Emergency Medical,Service, Medical Emergency,Services, Emergency Health,Services, Medical Emergency
D005103 Expert Systems Computer programs based on knowledge developed from consultation with experts on a problem, and the processing and/or formalizing of this knowledge using these programs in such a manner that the problems may be solved. Expert System,System, Expert,Systems, Expert
D005260 Female Females
D005996 Nitroglycerin A volatile vasodilator which relieves ANGINA PECTORIS by stimulating GUANYLATE CYCLASE and lowering cytosolic calcium. It is also sometimes used for TOCOLYSIS and explosives. Glyceryl Trinitrate,Anginine,Dynamite,Gilustenon,Nitrangin,Nitro-Bid,Nitro-Dur,Nitrocard,Nitroderm,Nitroderm TTS,Nitroglyn,Nitrol,Nitrolan,Nitrong,Nitrospan,Nitrostat,Perlinganit,Susadrin,Sustac,Sustak,Sustonit,Transderm Nitro,Tridil,Trinitrin,Trinitrolong,Nitro Bid,Nitro Dur,NitroBid,NitroDur,Trinitrate, Glyceryl
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man

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