Computer Patient Interviewing: Instant Medical History & UK Experience

Computer Patient Interviewing
Instant Medical History
and UK Experience
#DHOx Digital Health In Primary Care
19 April 2016
Dr Richard Sills rosills1@gmail.com

Acklowledgements Declarations
I have a commercial relationship with Primetime Medical
Software Inc (developers of the “Instant Medical History” CPI
system)
Prof Ray Jones, Health Informatics, University of Plymouth
John Bachman MD, Professor of Primary Care, Mayo Clinic
Harry Longman, GPAccess
Jon Witte, Wiggly-Amps
#DHOx

Why particularly relevant
Apparent significant demand / resources mismatch in GP
Government and others talking about “e-mailing patients and
e-consultations”
Other industries have harnessed the “on-line experience”
Patients, doctors and GP staff - frustrated
#DHOx

Let's look at some history
#DHOx

Anyone recognise this man?
#DHOx

Anyone recognise this man?
A Canadian Physician, one of the four
founding Professors of John Hopkins
Hospital, he is described as the
Father of Modern Medicine.
#DHOx

Sir William Osler (1849-1919)
“Talk to the Patient for long enough
he will tell you what is wrong
with him”
#DHOx

“Toward Automating
the Medical History”
“...to relieve the physician from routine, although
important, time‑consuming activities, thereby
extending his capabilities to provide medical care. If
the time physicians spend in collecting, organizing,
recording, and retrieving data could be reduced, at
least in part, by information technology, more time
would be available for actual delivery of medical care
and at the same time the physician’s capabilities for
collecting information from patients would be
extended...” .
by Mayne, Weksel, and Sholz
#DHOx

extended...”
When was this published?
2007?
#DHOx

extended...”
2004?
#DHOx

extended...”
1996?
#DHOx

extended...”
1989?
#DHOx

extended...”
1988?
#DHOx

extended...”
1979?
#DHOx

extended...”
Before 1969?
#DHOx

extended...”
by Mayne, Weksel, and Sholz (1968)
#DHOx

Important reviews
Jones RB, Knill-Jones RP. Electronic Patient Record
Project: Direct Patient Input to the Record. Report for the
Strategy Division of the Information Management Group
of the NHS Management Executive: University of
Glasgow, 1994. (Updated 1997).
Bachman JW. The patient-computer interview: A
neglected tool that can aid the clinician. Mayo Clinic
Proceedings 2003;78(1):67-78.
Slack WV. Cybermedicine for the patient. American
Journal of Preventive Medicine 2007;32(5):S135-S136.
#DHOx

Highlights
Warner Slack paper 1960’s
Ray Jones paper 1990’s
Pringle, BMJ 1988
Prof Bachman literature review 2003
Slack WV. Cybermedicine for the patient.
Prof Bachman “evisits” 2010
#DHOx

Common conclusions
“A well designed computer system can be used
to interview patients about their medical history,
signs and symptoms”
“Such systems are acceptable to the majority
of patients”
“Systems give patients more time to think
about questions”
#DHOx

From 1968
“A branching series of questions is developed to
assist the medical history taking of the clinician.
Standard, carefully worded questions are used to
collect a history, with systems having hundreds
if not thousands of questions, but patients only
answering those relevant”
#DHOx

Professor Ray Jones
From the number of published research studies in
which computers have been successfully used to interview
patients, I think there is no need to spend
time discussing the following:
A well designed computer system can be used to
interview patients about their medical history,
signs and symptoms.
Such systems are acceptable to the majority of
patients
@rjonesplymouth
#DHOx

Dr M Pringle
“Computers may be used acceptably to gather
accurate information and to improve medical
decisions without diminishing the role of the
doctor”
Using computers to take patient histories,
M Pringle, Nottingham University Medical School,
BMJ volume 297, Sept 1988
#DHOx

Professor John Bachman MD
“Computer Patient Interviewing is valid”
“Instant Medical History is the World leader”
Bachman JW. The patient-computer interview: A
neglected tool that can aid the clinician. Mayo Clinic
Proceedings 2003;78(1): 67-78.
#DHOx

Can a computer take a Psychiatric History?
“A program on an inexpensive microcomputer was designed to elicit
personal histories from patients in a general psychiatric ward. Their
answers were compared with the information recorded by the responsible
psychiatric team. Where answers disagreed with the clinicians' records, the
patient was interviewed to investigate the discrepancy”
“Most patients' computer histories revealed several items unknown to the
clinicians and of importance in the management of the patient. Most
patients (88%) found that the computer interrogation was as easy as a
clinical interview”
“Computer assessment is proposed as a useful technique for the routine
assessment of patients to augment the clinician's findings and to allow her
to concentrate on the most relevant areas”
Carr AC. Ghosh A. Ancill RJ. Can a computer take a
psychiatric history? Psychological Medicine. 13(1):151-8,
1983 Feb.
#DHOx

Comparison of computer-based personal interviews
“A computer-based questionnaire can generate responses that are
equivalent to the responses to a traditional personal interview. In
some cases, a computer may be more successful in eliciting risk
factors”
Hasley S A comparison of computer-based and personal
interviews for the gynecologic history update. Obstetrics
Gynecology. 85(4):494-8, 1995 Apr.
#DHOx

Mayo Clinic eVisits 2010
“The e-visits made surgery visits unnecessary in 1012
cases (40%)”
“In the basic e-visit process, patients entered their
reported problem in free text (eg, “back pain”) and
then answered questions one at a time. The questions
branched such that the history was organised into a
readable clinical format”
Pilot Study of Providing Online Care in a Primary
Care Setting Steven C. Adamson, MD, and John W.
Bachman, MD. Mayo Clinic Proceedings August
2010 vol. 85 no. 8704-710
#DHOx

History taking: How do we perform?
Physicians miss 54% of patients problems and
45% of their concerns
In 50% of visits patients and doctors do not
agree on the presenting problem
50% of psychological problems are missed
Only 23 seconds before patient is interrupted
(12 secs for medical residents)
Biggest complaint in patient “satisfaction” is poor
physician communication skills.
(See Bachman Literature review for references)
#DHOx

History taking: how does the
Computer Perform?
#DHOx

Strengths of Computerised interview
Structured, all questions are asked
Does not Interrupt
Good at obtaining sensitive information
Patients better prepared for a subsequent face to
face consultation
Legible summaries and direct input to Electronic Record
Scales calculated well
Effective at improving care quality
#DHOx

Strengths of Computerised interview
All questions usually answered
Can be done anywhere, at Patient’s pace
with family help
Different languages
Better data- better research
Checklist
Does not require Clinician’s time
Acceptable to Patients in multiple studies
#DHOx

Patient can complete as little or
as much as they feel able and the
depth of questioning can be tailored
to suit the clinical setting
#DHOx

Computers show no embarrassment
in asking important questions where
responses deem that question is
worth answering
#DHOx

Presenting Complaint
A M is a 13 year old male. His reason for visit is “Pre-Participation Sports Examination”
Past, Family, and Social History
Accidents and injuries
History of: Concussion. Injuries: torn ligaments. Head injury. Broken
leg Head laceration.
Family History
Mother
History of: Asthma
Social History
History of: Physical assault less than 2 months ago and by unknown person
Allergy History
History of: No allergies to medicines, pollen, foods or stinging insects
PreviousTests
History of: Previous investigation included an X-Ray of the shoulder. Doesn't know number of leg
X-Rays. Doesn't know number of arm X-Rays.
Review of Systems
Eye
He reported: Recent vision changes
Neurologic
He reported: Pins and needles after injury.. Paralysis after injury. Headaches sometimes
precipitated or aggravated by exertion.
Risk Factors, Prevention, and Patient Issues
Prevention
He reported: Not wearing protective eyewear and sometimes not wearing a seat belt in a car.
#DHOx

ENT
History of Ear surgery for infection
Accidents and Injuries
History of Concussion. Bone fracture. Post head injury confusion and fatigue. Memory loss a few seconds
before injury. Injury from ligaments. Head injury. Loss of consciousness Immediately at time of injury, a few
seconds after injury, and for an undetermined time period. Torn ligament of the right foot. Rib sprains.
Neck sprain. Sprained middle back. Doesn't know Number of leg sprains. One leg torn ligament. Head
laceration.
Family History
History of Heart disease (immediate family), Asthma (distant family).
Sister
History of Asthma
Social History
History of Thinking someone in family has a substance abuse problem
Activities for Daily Living
History of Sports participation restricted for health reasons
Substance Use
Tobacco Use
History of Friend or family use tobacco
Alcohol
History of Alcohol intake
Drug Usage
History of Friends bring alcohol to School
Medication History
Ongoing Medications
History of Prescription medication for more than 3 months. Medication stopped in the last month
and
dosage change. Prescribed medication very effective. Medications prescribed by another
physician. Most
of the time compliant with Prescription. Inhaler use.
Over-the-counter Medications
History of Non-prescription medication
Complementary Medicines
History of Nutritional supplements in last month and for weight gain
Adverse Drug Reactions
#DHOx

Patients collect info that Clinicians miss
40% of the time the questionnaire provided
useful information that would not be typically
elicited
Essential Questions aren't missed
Pilot’s Checklist
#DHOx

Particularly relevant
Psychological issues
Illicit Drugs
Alcohol
Documentation
Evidence strongly suggests that people will be
more honest with the CPI than face to face.
#DHOx

Completeness
CPI ensures that lines of investigation are not forgotten, leading to more
complete data and fewer errors in diagnosis and better agreement between
Patient and Doctor.
For example, a recent German hospital study found that computer histories
reported an additional average of 3.5 problems per patient which were not
recorded in corresponding physician histories. The authors recommended a
combination of computer and physician histories as the best method.
Zakim D, Braun N, Fritz P, Alscher MD. Underutilization of information and knowledge
in everyday medical practice: Evaluation of a computer-based solution. BMC Medical
Informatics and Decision Making 2008;8:12.
#DHOx

Alcohol
Alcoholic Captain
“Wanted to be caught”
Wasn’t asked the right questions
CPI would have asked
#DHOx

Let Patients do the work
The use of Computer Patient Interviewing allows patients
to give a very full history whilst saving the clinicians time.
This will capture sensitive information at least as well as
a face to face questions and probably more reliably.
Many more direct questions can be asked.
Standard Instruments can be administered and scored
as a routine (PHQ-9, GAD-7 etc)
#DHOx

Outcomes of using CPI
More complete questioning.
Better documentation which in turn will enhance the
ability to compare responses over time.
Much better coded symptom data.
Standard Instruments scored.
Improved assessment and particularly Psychological /
sensitive issues.
Increased efficiency
#DHOx

Change Management in Healthcare
“That the stethoscope will ever come into general use,
notwithstanding its value, is extremely doubtful because its
beneficial application requires much time and gives a good
bit of trouble, both to the patient and the practitioner
because it's hue and character are foreign and opposed to
all our habits and associations”
The Times 1834
#DHOx

Instant Medical History: UK Experience
Implementation Partner:
Wiggly-Amps.com #DHOx

Proof of Concept:
http://www.htmc.co.uk/pages/pv.asp?p=htmc0473
@AmirHannan #DHOx

#DHOx
An implementation:
3GDoctor.com #DHOx

#DHOx
An implementation:
World's first Mobile Video Consulting service
Private documented Consults available 24x7
(UK Ireland only)
Launched November 2006
Best Practice in Video Consulting (Doctors 2.0 Paris):
https://www.youtube.com/watch?v=z4JoJnRbsbI
#DHOx

An implementation:
AskMyGP .UK #DHOx

An implementation:
AskMyGP .UK
More than 20,000 Patients used the
service with their GP in the first 5 weeks

An implementation:
AskMyGP .UK
If you have a GP Practice and would like to
implement AskMyGP contact Harry@GPAccess.uk

Patients quickly adapt to online access: At Botolph
Bridge 40% of demand moved online in 2 weeks.

Demand follows predictable daily pattern, high
Mondays, low weekends

Patients are interacting with the service in working
hours spread is better than with Telephone rush

All Ages are accessing online (from 0-102 years).
60/40 Female/Male split is usual for GP Demand.

73% of Patients want help from anyone,
27% request named GP 10% want most popular GP.

5,000 symptoms entered resolve into 320 different
groups (and counting)

Top 10, Family Practice, Peterborough

Children under 5, North London

Adults aged 20-60, Deprived Area, Scotland

87% presented with single problem.
13% presented with more than one problem.

50% of demand is a new problem,
21% is follow up 29% an existing condition.

Duration: Most sessions take between 2 12 mins,
Median is 6 mins, all in Patients own time.

Patient Feedback: 57% say new system is better,
37% same and only 8% say worse.

Past month: 60% say new service is better, including
63% aged 60+ and 64% used service more than once.

Comments: over 1000 comments posted online
Like the convenience, and 4/5 recommend
Quicker than phone
Late in the evening
GP or message suggested new service
Some appreciate the questions
Thorough, questions good
allowed me to express concerns
Like not having to explain to a receptionist
Some feel it’s too much
Too many questions
Some not relevant

Comments: examples
This seems like a good
way not having to explain
your private symptoms to
the receptionist.
This seems like a good
way not having to explain
your private symptoms to
the receptionist.
I like this; I don't have a lot
of time to wait on the phone
so would prefer to deal
online. I can see myself
using this all the time now.
I like this; I don't have a lot
of time to wait on the phone
so would prefer to deal
online. I can see myself
using this all the time now.
been excellent
so far!
been excellent
so far!
I used this system
because of the delay in
a telephone call to the
surgery taking a long
time to answer.
I used this system
because of the delay in
a telephone call to the
surgery taking a long
time to answer.
I felt as if it asked a lot of
questions, some didn't
appear to me as a lay
person to be relevant
I felt as if it asked a lot of
questions, some didn't
appear to me as a lay
person to be relevantUsed because of difficulty
contacting practice while I
am at work. It is not always
convenient to discuss
personal issues.
Used because of difficulty
contacting practice while I
am at work. It is not always
convenient to discuss
personal issues.

We have learned...
Patients are adopting fast
– Simple interface which works on any device
– Need freedom to ask any question, 2/3 are medical, 1/3 other
– Rapid response is crucial – 23 minute average to date
– Consistent message from practice staff, phone messages SMS
All ages are using it
– 0 – 102 year old patients
– 14 % are parents and 4% carers
– Analyse symptoms by age groups, location
Demand is closely matched to opening hours
– Very low at weekends
– High Mondays, tails off through the week
– Mornings twice the level of afternoons
–

Thank you for your interest
Dr Richard Sills
rosills1@gmail.com
+44 (0) 7940836337

https://www.youtube.com/watch?v=uY32p_BqPw0

“Yes, yes, Mrs Jones... ...we'll talk about your chest pain in one
minute. Right now I'm just trying to remember my password”

A machine cannot come between
me and my Patient!
All of this is true
It need not happen

A case (thanks to Prof Bachman)
A patient who has hypertension comes to see you
because in the last ten days she has noted that her
blood pressure is elevated from its baseline.
Meds Lisinopril 20 mg daily
BP 152/93

Chief Complaint
Time/Date
Sonk is a 65 year old female. Her reason for visit is “Hypertension” 13:34pm. April 17, 2003
History of Present Illness
SOnk reported: palpitations. Irregular, missed, or skipped heart beats.
SOnk denied: angina pectoris. Pressure or pain in chest. Pale or white episodes sometimes.
Past, Family and Social History
Past Medical History
History of: last blood pressure high. Hypertension within five to ten years. Hypercholesterolemia.
Hypertriglyceridemia.
Family History
History of family members with high blood pressure.
Social History
Alcohol
History of: alcohol use weekly
Medication History
Ongoing Medications
History of: female hormoe medication. Conjugated estrogens. Non-prescription non-steroidal
anti-
inflammatory medication for pain.
Past Medications
History of: estrogen replacement hormones. Estorgen and progesterone combination
replacement hormones. Estrogen progresterone combination therapy 11 to 15 years. Estrogen
replacement therapy 11 to 15 years. Oral contraceptives.
Review of Systems
Constitutional Respiratory
SOnk denied: Overweight SOnk denied: dyspnea.
Genitourinary Skin
SOnk denied: dyspnea. SOnk denied: acne
Musculoskeletal Psychiatric
SOnk denied: legs painful. SOnk denied: recent stress
Neurological Skin
SOnk denied: headaches. Tremulousness. SOnk reported: Paresis
Risk Factors
Physical Conditioning Nutrition
SOnk reported: 30 min per day exercise SOnk reported: Eating imported licorice

WHAT A DOC!!!!!
1) Her B/P is coming down: 138/80 and now 128/78
2) Her “numb feet” have responded well to the iron
supplements. She is glad.
3) She has stopped her licorice and excess salt intake
4) She thanks you for sending her to the Patient
Education class on Hypertension and YES you were right
– she did learn something! This IS the truth and nothing
but the truth....
A case (thanks to Prof Bachman)

What can we learn from this?
We can not judge quality of care by reviewing
a chart!
Inputs are important
Computerised history provided more information
that was critical to this case, and was valuable
to the clinician

CPI allows patients to more easily disclose information
about embarrassing topics eg. computer interviewing for
pelvic floor symptoms in both primary care and hospital
found ‘Despite the taboo nature of many of the items, the
questionnaire was well received by women in both settings’
Radley SC, Jones GL, Tanguy EA, Stevens VG, Nelson C, Mathers
NJ. Computer interviewing in urogynaecology: concept,
development and psychometric testing of an electronic pelvic
floor assessment questionnaire in primary and secondary care.
BJOG 2006;113(2):231-238.
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