Introduction The medical history is the fundamental basis of diagnosis. Every medical student learns how to take a full history, but in clinical practice the history is often truncated due to pressures of various kinds. Many clinicians use pre-consultation forms to collect relevant history, but these are rigid and cannot include the complete medical history.
Methods We have developed a large database of questions that could be asked during history taking. A computerised algorithm selects the next relevant question depending on the previous answer. A designer interface allows questionnaires to be developed and adjusted readily. The questions are phrased in plain English, but the program translates the answers into medical terminology. The history is then available in PDF format for presentation to the clinician. Patients self completed their history using a touch screen, and checked the results before printing. Comments about the process were recorded from patients and clinical staff. The system was trialled in a hepatitis assessment clinic. Patients are fully informed about this voluntary and secure system prior to use.
Results 443 patients used the touch screen. 12 did not complete their history because of language problems (8) or indifference (3). The average time to complete was 14.7 min (range 7–21 min). 7 patients were identified who were at high risk of hepatitis infection, and a monospot test was offered and accepted in all of these and further serological tests undertaken. 180 patients with known positive serology completed their history.
Conclusion Patients found the touch screen easy to use, and were able to complete their history in the waiting area prior to consultation. They were universally happy to keep a printout of their history. The clinicians were able to spend more time discussing risks and treatment options, and were able to ask supplementary questions rather than repeatedly obtaining basic data. Printouts of the PDF were retained in the notes as part of the medical record. This technology has shown great potential in allowing more new patients to be seen, increasing efficiency in carrying out regular reviews, gathering better clinical information and reducing patient distress when asking sensitive questions. Perceived benefits are – more rapid and thorough clinical assessment; semi-automated follow up; health screening; and patient surveys. There are applications for this technology in many fields of medical practice.
Disclosure of Interest None Declared.
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