Techniques for physician review of patient history data in the HELP computer system

The patient medical history is a necessary and critical tool for making diagnostic decisions. Recently the HELP hospital information system implemented a plan to collect a patient's history via a computer-directed, self-administered questionnaire. Because this method removed physicians from the history taking process, and scheme was devised to report the history and allow the physicians to directly edit patient responses. To determine the most efficeint means of presenting this information, two review formats were made available. One format presented data via medical system or speciality. The other displayed data that generated computer-suggested diagnoses. The system was made available on a trial basis in two hospital rooms. Bedside terminals were provided to allow patients to take their own histories and allow physicians to review the history information on their patient rounds. Results showed that while patients overwhelmingly accepted the history taking process, physicians could not find the time to review the information through computer terminals. The physicians preferred to review the computer-acquired historical data by printed reports. Interviews were used to gather additional information from the participating physicians. This paper describes the history reporting/reviewing process and presents a basic understanding of the history taking process