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Brandberg H, Sundberg CJ, Spaak J, Koch S, Kahan T. Are medical history data fit for risk stratification of patients with chest pain in emergency care? Comparing data collected from patients using computerized history taking with data documented by physicians in the electronic health record in the CLEOS-CPDS prospective cohort study. J Am Med Inform Assoc 2024:ocae110. [PMID: 38781350 DOI: 10.1093/jamia/ocae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/02/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE In acute chest pain management, risk stratification tools, including medical history, are recommended. We compared the fraction of patients with sufficient clinical data obtained using computerized history taking software (CHT) versus physician-acquired medical history to calculate established risk scores and assessed the patient-by-patient agreement between these 2 ways of obtaining medical history information. MATERIALS AND METHODS This was a prospective cohort study of clinically stable patients aged ≥ 18 years presenting to the emergency department (ED) at Danderyd University Hospital (Stockholm, Sweden) in 2017-2019 with acute chest pain and non-diagnostic ECG and serum markers. Medical histories were self-reported using CHT on a tablet. Observations on discrete variables in the risk scores were extracted from electronic health records (EHR) and the CHT database. The patient-by-patient agreement was described by Cohen's kappa statistics. RESULTS Of the total 1000 patients included (mean age 55.3 ± 17.4 years; 54% women), HEART score, EDACS, and T-MACS could be calculated in 75%, 74%, and 83% by CHT and in 31%, 7%, and 25% by EHR, respectively. The agreement between CHT and EHR was slight to moderate (kappa 0.19-0.70) for chest pain characteristics and moderate to almost perfect (kappa 0.55-0.91) for risk factors. CONCLUSIONS CHT can acquire and document data for chest pain risk stratification in most ED patients using established risk scores, achieving this goal for a substantially larger number of patients, as compared to EHR data. The agreement between CHT and physician-acquired history taking is high for traditional risk factors and lower for chest pain characteristics. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT03439449.
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Affiliation(s)
- Helge Brandberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm SE-182 88, Sweden
| | - Carl Johan Sundberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm SE-171 77, Sweden
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm SE-171 77, Sweden
| | - Jonas Spaak
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm SE-182 88, Sweden
| | - Sabine Koch
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm SE-171 77, Sweden
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm SE-182 88, Sweden
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Harada Y, Tomiyama S, Sakamoto T, Sugimoto S, Kawamura R, Yokose M, Hayashi A, Shimizu T. Effects of Combinational Use of Additional Differential Diagnostic Generators on the Diagnostic Accuracy of the Differential Diagnosis List Developed by an Artificial Intelligence-Driven Automated History-Taking System: Pilot Cross-Sectional Study. JMIR Form Res 2023; 7:e49034. [PMID: 37531164 PMCID: PMC10433017 DOI: 10.2196/49034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/23/2023] [Accepted: 07/19/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Low diagnostic accuracy is a major concern in automated medical history-taking systems with differential diagnosis (DDx) generators. Extending the concept of collective intelligence to the field of DDx generators such that the accuracy of judgment becomes higher when accepting an integrated diagnosis list from multiple people than when accepting a diagnosis list from a single person may be a possible solution. OBJECTIVE The purpose of this study is to assess whether the combined use of several DDx generators improves the diagnostic accuracy of DDx lists. METHODS We used medical history data and the top 10 DDx lists (index DDx lists) generated by an artificial intelligence (AI)-driven automated medical history-taking system from 103 patients with confirmed diagnoses. Two research physicians independently created the other top 10 DDx lists (second and third DDx lists) per case by imputing key information into the other 2 DDx generators based on the medical history generated by the automated medical history-taking system without reading the index lists generated by the automated medical history-taking system. We used the McNemar test to assess the improvement in diagnostic accuracy from the index DDx lists to the three types of combined DDx lists: (1) simply combining DDx lists from the index, second, and third lists; (2) creating a new top 10 DDx list using a 1/n weighting rule; and (3) creating new lists with only shared diagnoses among DDx lists from the index, second, and third lists. We treated the data generated by 2 research physicians from the same patient as independent cases. Therefore, the number of cases included in analyses in the case using 2 additional lists was 206 (103 cases × 2 physicians' input). RESULTS The diagnostic accuracy of the index lists was 46% (47/103). Diagnostic accuracy was improved by simply combining the other 2 DDx lists (133/206, 65%, P<.001), whereas the other 2 combined DDx lists did not improve the diagnostic accuracy of the DDx lists (106/206, 52%, P=.05 in the collective list with the 1/n weighting rule and 29/206, 14%, P<.001 in the only shared diagnoses among the 3 DDx lists). CONCLUSIONS Simply adding each of the top 10 DDx lists from additional DDx generators increased the diagnostic accuracy of the DDx list by approximately 20%, suggesting that the combinational use of DDx generators early in the diagnostic process is beneficial.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Shimotsugagun, Japan
- Department of Internal Medicine, Nagano Chuo Hospital, Nagano, Japan
| | - Shusaku Tomiyama
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Shimotsugagun, Japan
| | - Tetsu Sakamoto
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Shimotsugagun, Japan
| | - Shu Sugimoto
- Department of Internal Medicine, Nagano Chuo Hospital, Nagano, Japan
| | - Ren Kawamura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Shimotsugagun, Japan
| | - Masashi Yokose
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Shimotsugagun, Japan
| | - Arisa Hayashi
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Shimotsugagun, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Shimotsugagun, Japan
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Noack EM, Zajontz D, Friede T, Antweiler K, Hummers E, Schmidt T, Roddewig L, Schröder D, Müller F. Evaluating an app for digital medical history taking in urgent care practices: study protocol of the cluster-randomized interventional trial 'DASI'. BMC PRIMARY CARE 2023; 24:108. [PMID: 37106447 PMCID: PMC10133907 DOI: 10.1186/s12875-023-02065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND In out-of-hours urgent care practices in Germany, physicians of different specialties care for a large number of patients, most of all unknown to them, resulting in a high workload and challenging diagnostic decision-making. As there is no common patient file, physicians have no information about patients' previous conditions or received treatments. In this setting, a digital tool for medical history taking could improve the quality of medical care. This study aims to implement and evaluate a software application (app) that takes a structured symptom-oriented medical history from patients in urgent care settings. METHODS We conduct a time-cluster-randomized trial in two out-of-hours urgent care practices in Germany for 12 consecutive months. Each week during the study defines a cluster. We will compare participants with (intervention group) and without app use (control group) prior to consultation and provision of the self-reported information for the physician. We expect the app to improve diagnostic accuracy (primary outcome), reduce physicians' perceived diagnostic uncertainty, and increase patients' satisfaction and the satisfaction with communication of both physician and patient (secondary outcomes). DISCUSSION While similar tools have only been subject to small-scale pilot studies surveying feasibility and usability, the present study uses a rigorous study design to measure outcomes that are directly associated with the quality of delivered care. TRIAL REGISTRATION The study was registered at the German Clinical Trials Register (No. DRKS00026659 registered Nov 03 2021. World Health Organization Trial Registration Data Set, https://trialsearch.who.int/Trial2.aspx? TrialID = DRKS00026659.
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Affiliation(s)
- Eva Maria Noack
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany.
| | - Dagmar Zajontz
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, 37073, Göttingen, Germany
| | - Kai Antweiler
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, 37073, Göttingen, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Tobias Schmidt
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
- Department of Performance, Neuroscience, Therapy and Health, MSH Medical School Hamburg, Kaiserkai 1, 20457, Hamburg, Germany
| | - Lea Roddewig
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Dominik Schröder
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Frank Müller
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
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Eshel R, Bellolio F, Boggust A, Shapiro NI, Mullan AF, Heaton HA, Madsen BE, Homme JL, Iliff BW, Sunga KL, Wangsgard CR, Vanmeter D, Cabrera D. Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department. Am J Emerg Med 2023; 63:79-85. [PMID: 36327754 DOI: 10.1016/j.ajem.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/05/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians. METHODS Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa. RESULTS A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified. CONCLUSION Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.
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Affiliation(s)
- Ron Eshel
- Department of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Andy Boggust
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Diagnostics Robotics. Tel Aviv, Israel
| | - Aidan F Mullan
- Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States
| | - Heather A Heaton
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Bo E Madsen
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - James L Homme
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Benjamin W Iliff
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kharmene L Sunga
- Department of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Derek Vanmeter
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States.
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Chen Y, Lin Q, Chen X, Liu T, Ke Q, Yang Q, Guan B, Ming WK. Need assessment for history-taking instruction program using chatbot for nursing students: A qualitative study using focus group interviews. Digit Health 2023; 9:20552076231185435. [PMID: 37426591 PMCID: PMC10328012 DOI: 10.1177/20552076231185435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 06/14/2023] [Indexed: 07/11/2023] Open
Abstract
Purpose A comprehensive health history contributes to identifying the most appropriate interventions and care priorities. However, history-taking is challenging to learn and develop for most nursing students. Chatbot was suggested by students to be used in history-taking training. Still, there is a lack of clarity regarding the needs of nursing students in these programs. This study aimed to explore nursing students' needs and essential components of chatbot-based history-taking instruction program. Methods This was a qualitative study. Four focus groups, with a total of 22 nursing students, were recruited. Colaizzi's phenomenological methodology was used to analyze the qualitative data generated from the focus group discussions. Results Three main themes and 12 subthemes emerged. The main themes included limitations of clinical practice for history-taking, perceptions of chatbot used in history-taking instruction programs, and the need for history-taking instruction programs using chatbot. Students had limitations in clinical practice for history-taking. When developing chatbot-based history-taking instruction programs, the development should reflect students' needs, including feedback from the chatbot system, diverse clinical situations, chances to practice nontechnical skills, a form of chatbot (i.e., humanoid robots or cyborgs), the role of teachers (i.e., sharing experience and providing advice) and training before the clinical practice. Conclusion Nursing students had limitations in clinical practice for history-taking and high expectations for chatbot-based history-taking instruction programs.
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Affiliation(s)
- Yanya Chen
- School of Nursing, Jinan University, Guangzhou, China
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, Hong Kong
| | - Qingran Lin
- School of Nursing, Jinan University, Guangzhou, China
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaohan Chen
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, Hong Kong
| | - Taoran Liu
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, Hong Kong
| | - Qiqi Ke
- School of Nursing, Jinan University, Guangzhou, China
| | - Qiaohong Yang
- School of Nursing, Jinan University, Guangzhou, China
| | - Bingsheng Guan
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wai-kit Ming
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, Hong Kong
- School of Public Policy and Management, Tsinghua University, China
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Berdahl CT, Henreid AJ, Pevnick JM, Zheng K, Nuckols TK. Digital Tools Designed to Obtain the History of Present Illness From Patients: Scoping Review. J Med Internet Res 2022; 24:e36074. [PMID: 36394945 PMCID: PMC9716422 DOI: 10.2196/36074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/25/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Many medical conditions, perhaps 80% of them, can be diagnosed by taking a thorough history of present illness (HPI). However, in the clinical setting, situational factors such as interruptions and time pressure may cause interactions with patients to be brief and fragmented. One solution for improving clinicians’ ability to collect a thorough HPI and maximize efficiency and quality of care could be to use a digital tool to obtain the HPI before face-to-face evaluation by a clinician.
Objective
Our objective was to identify and characterize digital tools that have been designed to obtain the HPI directly from patients or caregivers and present this information to clinicians before a face-to-face encounter. We also sought to describe outcomes reported in testing of these tools, especially those related to usability, efficiency, and quality of care.
Methods
We conducted a scoping review using predefined search terms in the following databases: MEDLINE, CINAHL, PsycINFO, Web of Science, Embase, IEEE Xplore Digital Library, ACM Digital Library, and ProQuest Dissertations & Theses Global. Two reviewers screened titles and abstracts for relevance, performed full-text reviews of articles meeting the inclusion criteria, and used a pile-sorting procedure to identify distinguishing characteristics of the tools. Information describing the tools was primarily obtained from identified peer-reviewed sources; in addition, supplementary information was obtained from tool websites and through direct communications with tool creators.
Results
We identified 18 tools meeting the inclusion criteria. Of these 18 tools, 14 (78%) used primarily closed-ended and multiple-choice questions, 1 (6%) used free-text input, and 3 (17%) used conversational (chatbot) style. More than half (10/18, 56%) of the tools were tailored to specific patient subpopulations; the remaining (8/18, 44%) tools did not specify a target subpopulation. Of the 18 tools, 7 (39%) included multilingual support, and 12 (67%) had the capability to transfer data directly into the electronic health record. Studies of the tools reported on various outcome measures related to usability, efficiency, and quality of care.
Conclusions
The HPI tools we identified (N=18) varied greatly in their purpose and functionality. There was no consensus on how patient-generated information should be collected or presented to clinicians. Existing tools have undergone inconsistent levels of testing, with a wide variety of different outcome measures used in evaluation, including some related to usability, efficiency, and quality of care. There is substantial interest in using digital tools to obtain the HPI from patients, but the outcomes measured have been inconsistent. Future research should focus on whether using HPI tools can lead to improved patient experience and health outcomes, although surrogate end points could instead be used so long as patient safety is monitored.
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Affiliation(s)
- Carl T Berdahl
- Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | | | | | - Kai Zheng
- University of California Irvine Donald Bren School of Information and Computer Sciences, Irvine, CA, United States
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Sundberg K, Adeli A, Brandberg H, Spaak J, Koch S, Sundberg CJ, Zakim D, Kahan T, Fritzell K. User experience of self-reported computerized medical history taking for acute chest pain: The Clinical Expert Operating System Chest Pain Danderyd Study. Health Expect 2022; 25:3053-3061. [PMID: 36148691 DOI: 10.1111/hex.13612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 09/01/2022] [Accepted: 09/10/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Chest pain is one of the most common complaints in emergency departments (EDs). Self-reported computerized history taking (CHT) programmes can be used for interpretation of the clinical significance of medical information coming directly from patients. The adoption of CHT in clinical practice depends on reactions and attitudes to the technology from patients and their belief that the technology will have benefits for their medical care. The study objective was to explore the user experience of the self-reported CHT programme Clinical Expert Operating System (CLEOS) in the setting of patients visiting an ED for acute chest pain. METHODS This qualitative interview study is part of the ongoing CLEOS-Chest Pain Danderyd Study. A subset (n = 84) of the larger sample who had taken part in self-reported history taking during waiting times at the ED were contacted by telephone and n = 54 (64%) accepted participation. An interview guide with open-ended questions was used and the text was analysed using directed content analysis. RESULTS The patients' experiences of the CLEOS programme were overall positive although some perceived it as extensive. The programme was well accepted and despite the busy environment, patients were highly motivated and deemed it helpful to make a diagnosis. Six categories of user experience emerged: The clinical context, The individual context, Time aspect, Acceptability of the programme, Usability of the programme and Perceptions of usefulness in a clinical setting. CONCLUSIONS The programme was well accepted by most patients in the stressful environment at ED although some found it difficult to answer all the questions. Adjustments to the extent of an interview to better suit the context of the clinical use should be a future development of the programme. The findings suggest that CHT programmes can be integrated as a standard process for collecting self-reported medical history data in the ED setting.
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Affiliation(s)
- Kay Sundberg
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Athena Adeli
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Sweden
| | - Helge Brandberg
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Spaak
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Sabine Koch
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Sweden
| | - Carl J Sundberg
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Sweden.,Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - David Zakim
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Kahan
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Kaisa Fritzell
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden.,Cancer Theme, Reception Hereditary Cancer, Karolinska University Hospital, Stockholm, Sweden
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Albrink K, Joos C, Schröder D, Müller F, Hummers E, Noack EM. Obtaining patients' medical history using a digital device prior to consultation in primary care: study protocol for a usability and validity study. BMC Med Inform Decis Mak 2022; 22:189. [PMID: 35854290 PMCID: PMC9297616 DOI: 10.1186/s12911-022-01928-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background With the help of digital tools patients’ medical histories can be collected quickly and transferred into their electronic medical records. This information can facilitate treatment planning, reduce documentation work, and improve care. However, it is still unclear whether the information collected from patients in this way is reliable. In this study, we assess the accuracy of the information collected by patients using an app for medical history taking by comparing it with the information collected in a face-to-face medical interview. We also study the app’s usability from the patients’ point of view and analysing usage data. Methods We developed a software application (app) for symptom-oriented medical history taking specialized for general practice. Medical history taking will take place involving patients with acute somatic or psychological complaints (1) using the app and (2) verbally with trained study staff. To assess the perceived usability, patients will complete a questionnaire for the System Usability Scale. We will collect sociodemographic data, information about media use and health literacy, and app usage data.
Discussion Digital tools offer the opportunity to improve patient care. However, it is not self-evident that the medical history taken by digital tools corresponds to the medical history that would be taken in an interview. If simply due to a design flaw patients answer questions about signs and symptoms that indicate possible serious underlying conditions ‘wrong’, this could have severe consequences. By additionally assessing the app’s usability as perceived by a diverse group of patients, potential weaknesses in content, design and navigation can be identified and subsequently improved. This is essential in order to ensure that the app meets the need of different groups of patients.
Trial registration German Clinical Trials Register DRKS00026659, registered Nov 03 2021. World Health Organization Trial Registration Data Set, https://trialsearch.who.int/Trial2.aspx? TrialID = DRKS00026659.
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Affiliation(s)
- Klara Albrink
- Department of General Practice, University Medical Center Göttingen, Georg-August-University of Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Carla Joos
- Department of General Practice, University Medical Center Göttingen, Georg-August-University of Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Dominik Schröder
- Department of General Practice, University Medical Center Göttingen, Georg-August-University of Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Frank Müller
- Department of General Practice, University Medical Center Göttingen, Georg-August-University of Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center Göttingen, Georg-August-University of Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Eva Maria Noack
- Department of General Practice, University Medical Center Göttingen, Georg-August-University of Göttingen, Humboldtallee 38, 37073, Göttingen, Germany.
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Kawamura R, Harada Y, Sugimoto S, Nagase Y, Katsukura S, Shimizu T. Incidence of diagnostic errors in unplanned hospitalized patients using an automated medical history-taking system with differential diagnosis generator: retrospective observational study (Preprint). JMIR Med Inform 2021; 10:e35225. [PMID: 35084347 PMCID: PMC8832260 DOI: 10.2196/35225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/11/2021] [Accepted: 01/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Automated medical history–taking systems that generate differential diagnosis lists have been suggested to contribute to improved diagnostic accuracy. However, the effect of these systems on diagnostic errors in clinical practice remains unknown. Objective This study aimed to assess the incidence of diagnostic errors in an outpatient department, where an artificial intelligence (AI)–driven automated medical history–taking system that generates differential diagnosis lists was implemented in clinical practice. Methods We conducted a retrospective observational study using data from a community hospital in Japan. We included patients aged 20 years and older who used an AI-driven, automated medical history–taking system that generates differential diagnosis lists in the outpatient department of internal medicine for whom the index visit was between July 1, 2019, and June 30, 2020, followed by unplanned hospitalization within 14 days. The primary endpoint was the incidence of diagnostic errors, which were detected using the Revised Safer Dx Instrument by at least two independent reviewers. To evaluate the effect of differential diagnosis lists from the AI system on the incidence of diagnostic errors, we compared the incidence of these errors between a group where the AI system generated the final diagnosis in the differential diagnosis list and a group where the AI system did not generate the final diagnosis in the list; the Fisher exact test was used for comparison between these groups. For cases with confirmed diagnostic errors, further review was conducted to identify the contributing factors of these errors via discussion among three reviewers, using the Safer Dx Process Breakdown Supplement as a reference. Results A total of 146 patients were analyzed. A final diagnosis was confirmed for 138 patients and was observed in the differential diagnosis list from the AI system for 69 patients. Diagnostic errors occurred in 16 out of 146 patients (11.0%, 95% CI 6.4%-17.2%). Although statistically insignificant, the incidence of diagnostic errors was lower in cases where the final diagnosis was included in the differential diagnosis list from the AI system than in cases where the final diagnosis was not included in the list (7.2% vs 15.9%, P=.18). Conclusions The incidence of diagnostic errors among patients in the outpatient department of internal medicine who used an automated medical history–taking system that generates differential diagnosis lists seemed to be lower than the previously reported incidence of diagnostic errors. This result suggests that the implementation of an automated medical history–taking system that generates differential diagnosis lists could be beneficial for diagnostic safety in the outpatient department of internal medicine.
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Affiliation(s)
- Ren Kawamura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
- Department of Internal Medicine, Nagano Chuo Hospital, Nagano, Japan
| | - Shu Sugimoto
- Department of Internal Medicine, Nagano Chuo Hospital, Nagano, Japan
| | - Yuichiro Nagase
- Department of Internal Medicine, Nagano Chuo Hospital, Nagano, Japan
| | - Shinichi Katsukura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
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10
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van Muilekom MM, Luijten MAJ, van Oers HA, Terwee CB, van Litsenburg RRL, Roorda LD, Grootenhuis MA, Haverman L. From statistics to clinics: the visual feedback of PROMIS® CATs. J Patient Rep Outcomes 2021; 5:55. [PMID: 34245390 PMCID: PMC8272760 DOI: 10.1186/s41687-021-00324-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background To reduce the burden of completing Patient-Reported Outcome Measures (PROMs), PROMIS® Computerized Adaptive Tests (CATs) are being implemented in pediatric clinical practice. We aimed to develop recommendations for visual feedback options for PROMIS CATs on individual item and domain score level as an evidence-based feedback recommendation for PROMIS CATs is lacking. Methods Focus groups were held with clinicians who use the KLIK PROM portal. Literature-based feedback options were provided to initiate group discussion. Data was analyzed using thematic coding method. Additionally, a questionnaire was sent out to assess patients’ (12-18y) and parents’ (child 0-18y) preference for individual item feedback. Data was analyzed using descriptive statistics. Results Six focus groups were held (N = 28 clinicians). Regarding individual item feedback, showing the complete item bank, with only responses to administered items in traffic light colors was preferred. For domain scores, line graphs were preferred, including numerical (T-)scores, reference and cut-off lines, and traffic light colors. Separate graphs per domain, ranked in order of importance and harmonization of directionality (‘higher = better’) were considered important. Questionnaire results (N = 31 patients/N = 131 parents) showed that viewing their own item responses was preferred above receiving no item feedback by 58.1% of the patients and 77.1% of the parents. Conclusions Based on the outcomes and after discussion with the Dutch-Flemish PROMIS National Center, recommendations for PROMIS CAT feedback options were developed. PROMIS CATs can now be used in clinical practice to help clinicians monitor patient outcomes, while reducing the burden of completing PROMs for patients significantly.
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Affiliation(s)
- Maud M van Muilekom
- Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Postbox 22660, 1100 DD, Amsterdam, The Netherlands
| | - Michiel A J Luijten
- Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Postbox 22660, 1100 DD, Amsterdam, The Netherlands.,Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Hedy A van Oers
- Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Postbox 22660, 1100 DD, Amsterdam, The Netherlands
| | - Caroline B Terwee
- Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Raphaële R L van Litsenburg
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Pediatric Oncology, Cancer Center Amsterdam, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Leo D Roorda
- Amsterdam Rehabilitation Research Center
- Reade, Amsterdam, The Netherlands
| | | | - Lotte Haverman
- Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Postbox 22660, 1100 DD, Amsterdam, The Netherlands.
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11
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Hall NJ, Berry SK, Aguilar J, Brier E, Shah P, Cheng D, Herman J, Stein T, Spiegel BMR, Almario CV. Impact of an Online Gastrointestinal Symptom History Taker on Physician Documentation and Charting Time: Pragmatic Controlled Trial. JMIR Form Res 2021; 5:e23599. [PMID: 33944789 PMCID: PMC8132977 DOI: 10.2196/23599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/18/2021] [Accepted: 04/11/2021] [Indexed: 11/28/2022] Open
Abstract
Background A potential benefit of electronic health records (EHRs) is that they could potentially save clinician time and improve documentation by auto-generating the history of present illness (HPI) in partnership with patients prior to the clinic visit. We developed an online patient portal called AEGIS (Automated Evaluation of Gastrointestinal [GI] Symptoms) that systematically collects patient GI symptom information and then transforms the data into a narrative HPI that is available for physicians to review in the EHR prior to seeing the patient. Objective This study aimed to compare whether use of an online GI symptom history taker called AEGIS improves physician-centric outcomes vs usual care. Methods We conducted a pragmatic controlled trial among adults aged ≥18 years scheduled for a new patient visit at 4 GI clinics at an academic medical center. Patients who completed AEGIS were matched with controls in the intervention period who did not complete AEGIS as well as controls who underwent usual care in the pre-intervention period. Of note, the pre-intervention control group was formed as it was not subject to contamination bias, unlike for post-intervention controls. We then compared the following outcomes among groups: (1) documentation of alarm symptoms, (2) documentation of family history of GI malignancy, (3) number of follow-up visits in a 6-month period, (4) number of tests ordered in a 6-month period, and (5) charting time (difference between appointment time and time the encounter was closed). Multivariable regression models were used to adjust for potential confounding. Results Of the 774 patients who were invited to complete AEGIS, 116 (15.0%) finished it prior to their visit. The 116 AEGIS patients were then matched with 343 and 102 controls in the pre- and post-intervention periods, respectively. There were no statistically significant differences among the groups for documentation of alarm symptoms and GI cancer family history, number of follow-up visits and ordered tests, or charting time (all P>.05). Conclusions Use of a validated online HPI-generation portal did not improve physician documentation or reduce workload. Given universal adoption of EHRs, further research examining how to optimally leverage patient portals for improving outcomes are needed.
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Affiliation(s)
- Natalie J Hall
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sameer K Berry
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jack Aguilar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Elizabeth Brier
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Parth Shah
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Derek Cheng
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jeremy Herman
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Theodore Stein
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Brennan M R Spiegel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, United States
| | - Christopher V Almario
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, United States
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12
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Brandberg H, Sundberg CJ, Spaak J, Koch S, Zakim D, Kahan T. Use of Self-Reported Computerized Medical History Taking for Acute Chest Pain in the Emergency Department - the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS): Prospective Cohort Study. J Med Internet Res 2021; 23:e25493. [PMID: 33904821 PMCID: PMC8114166 DOI: 10.2196/25493] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/12/2021] [Accepted: 03/16/2021] [Indexed: 01/23/2023] Open
Abstract
Background Chest pain is one of the most common chief complaints in emergency departments (EDs). Collecting an adequate medical history is challenging but essential in order to use recommended risk scores such as the HEART score (based on history, electrocardiogram, age, risk factors, and troponin). Self-reported computerized history taking (CHT) is a novel method to collect structured medical history data directly from the patient through a digital device. CHT is rarely used in clinical practice, and there is a lack of evidence for utility in an acute setting. Objective This substudy of the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS) aimed to evaluate whether patients with acute chest pain can interact effectively with CHT in the ED. Methods Prospective cohort study on self-reported medical histories collected from acute chest pain patients using a CHT program on a tablet. Clinically stable patients aged 18 years and older with a chief complaint of chest pain, fluency in Swedish, and a nondiagnostic electrocardiogram or serum markers for acute coronary syndrome were eligible for inclusion. Patients unable to carry out an interview with CHT (eg, inadequate eyesight, confusion or agitation) were excluded. Effectiveness was assessed as the proportion of patients completing the interview and the time required in order to collect a medical history sufficient for cardiovascular risk stratification according to HEART score. Results During 2017-2018, 500 participants were consecutively enrolled. The age and sex distribution (mean 54.3, SD 17.0 years; 213/500, 42.6% women) was similar to that of the general chest pain population (mean 57.5, SD 19.2 years; 49.6% women). Common reasons for noninclusion were language issues (182/1000, 18.2%), fatigue (158/1000, 15.8%), and inability to use a tablet (152/1000, 15.2%). Sufficient data to calculate HEART score were collected in 70.4% (352/500) of the patients. Key modules for chief complaint, cardiovascular history, and respiratory history were completed by 408 (81.6%), 339 (67.8%), and 291 (58.2%) of the 500 participants, respectively, while 148 (29.6%) completed the entire interview (in all 14 modules). Factors associated with completeness were age 18-69 years (all key modules: Ps<.001), male sex (cardiovascular: P=.04), active workers (all key modules: Ps<.005), not arriving by ambulance (chief complaint: P=.03; cardiovascular: P=.045), and ongoing chest pain (complete interview: P=.002). The median time to collect HEART score data was 23 (IQR 18-31) minutes and to complete an interview was 64 (IQR 53-77) minutes. The main reasons for discontinuing the interview prior to completion (n=352) were discharge from the ED (101, 28.7%) and tiredness (95, 27.0%). Conclusions A majority of patients with acute chest pain can interact effectively with CHT on a tablet in the ED to provide sufficient data for risk stratification with a well-established risk score. The utility was somewhat lower in patients 70 years and older, in patients arriving by ambulance, and in patients without ongoing chest pain. Further studies are warranted to assess whether CHT can contribute to improved management and prognosis in this large patient group. Trial Registration ClinicalTrials.gov NCT03439449; https://clinicaltrials.gov/ct2/show/NCT03439449 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2019-031871
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Affiliation(s)
- Helge Brandberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, SE-182 88 Stockholm, Sweden
| | - Carl Johan Sundberg
- Medical Management Centre and Health Informatics Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Spaak
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, SE-182 88 Stockholm, Sweden
| | - Sabine Koch
- Medical Management Centre and Health Informatics Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - David Zakim
- Medical Management Centre and Health Informatics Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, SE-182 88 Stockholm, Sweden
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13
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Verma M, Younossi Z. Integrating Patient-Reported Outcomes Within Routine Hepatology Care: A Prompt to Action. Hepatology 2021; 73:1570-1580. [PMID: 32918286 DOI: 10.1002/hep.31550] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Manisha Verma
- Department of Digestive Diseases and Transplantation, Einstein Healthcare Network, Philadelphia, PA
| | - Zobair Younossi
- Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
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14
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Efficacy of Artificial-Intelligence-Driven Differential-Diagnosis List on the Diagnostic Accuracy of Physicians: An Open-Label Randomized Controlled Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042086. [PMID: 33669930 PMCID: PMC7924871 DOI: 10.3390/ijerph18042086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 12/27/2022]
Abstract
Background: The efficacy of artificial intelligence (AI)-driven automated medical-history-taking systems with AI-driven differential-diagnosis lists on physicians’ diagnostic accuracy was shown. However, considering the negative effects of AI-driven differential-diagnosis lists such as omission (physicians reject a correct diagnosis suggested by AI) and commission (physicians accept an incorrect diagnosis suggested by AI) errors, the efficacy of AI-driven automated medical-history-taking systems without AI-driven differential-diagnosis lists on physicians’ diagnostic accuracy should be evaluated. Objective: The present study was conducted to evaluate the efficacy of AI-driven automated medical-history-taking systems with or without AI-driven differential-diagnosis lists on physicians’ diagnostic accuracy. Methods: This randomized controlled study was conducted in January 2021 and included 22 physicians working at a university hospital. Participants were required to read 16 clinical vignettes in which the AI-driven medical history of real patients generated up to three differential diagnoses per case. Participants were divided into two groups: with and without an AI-driven differential-diagnosis list. Results: There was no significant difference in diagnostic accuracy between the two groups (57.4% vs. 56.3%, respectively; p = 0.91). Vignettes that included a correct diagnosis in the AI-generated list showed the greatest positive effect on physicians’ diagnostic accuracy (adjusted odds ratio 7.68; 95% CI 4.68–12.58; p < 0.001). In the group with AI-driven differential-diagnosis lists, 15.9% of diagnoses were omission errors and 14.8% were commission errors. Conclusions: Physicians’ diagnostic accuracy using AI-driven automated medical history did not differ between the groups with and without AI-driven differential-diagnosis lists.
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15
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Balhara KS, Millstein JH. Partners in Narrative: Empowering Patient-Physician Partnerships in the Electronic Health Record. J Patient Exp 2020; 7:833-835. [PMID: 33457505 PMCID: PMC7786775 DOI: 10.1177/2374373520962608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Amidst the chorus of valid laments about the electronic health record (EHR) are voices calling our attention to its potential to enhance transmission of information, patient communication, and decision-making. Herein, we propose ideas which, in addition, may enhance the potential of physicians and patients to become better at storytelling through the EHR. Clinicians can partner with patients to create meaningful, personalized narratives which restore inclusivity and patient agency to the EHR.
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Affiliation(s)
- Kamna S Balhara
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey H Millstein
- Penn Medicine Regional Physician Group at Penn Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
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16
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Harada Y, Shimizu T. Impact of a Commercial Artificial Intelligence-Driven Patient Self-Assessment Solution on Waiting Times at General Internal Medicine Outpatient Departments: Retrospective Study. JMIR Med Inform 2020; 8:e21056. [PMID: 32865504 PMCID: PMC7490680 DOI: 10.2196/21056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 12/28/2022] Open
Abstract
Background Patient waiting time at outpatient departments is directly related to patient satisfaction and quality of care, particularly in patients visiting the general internal medicine outpatient departments for the first time. Moreover, reducing wait time from arrival in the clinic to the initiation of an examination is key to reducing patients’ anxiety. The use of automated medical history–taking systems in general internal medicine outpatient departments is a promising strategy to reduce waiting times. Recently, Ubie Inc in Japan developed AI Monshin, an artificial intelligence–based, automated medical history–taking system for general internal medicine outpatient departments. Objective We hypothesized that replacing the use of handwritten self-administered questionnaires with the use of AI Monshin would reduce waiting times in general internal medicine outpatient departments. Therefore, we conducted this study to examine whether the use of AI Monshin reduced patient waiting times. Methods We retrospectively analyzed the waiting times of patients visiting the general internal medicine outpatient department at a Japanese community hospital without an appointment from April 2017 to April 2020. AI Monshin was implemented in April 2019. We compared the median waiting time before and after implementation by conducting an interrupted time-series analysis of the median waiting time per month. We also conducted supplementary analyses to explain the main results. Results We analyzed 21,615 visits. The median waiting time after AI Monshin implementation (74.4 minutes, IQR 57.1) was not significantly different from that before AI Monshin implementation (74.3 minutes, IQR 63.7) (P=.12). In the interrupted time-series analysis, the underlying linear time trend (–0.4 minutes per month; P=.06; 95% CI –0.9 to 0.02), level change (40.6 minutes; P=.09; 95% CI –5.8 to 87.0), and slope change (–1.1 minutes per month; P=.16; 95% CI –2.7 to 0.4) were not statistically significant. In a supplemental analysis of data from 9054 of 21,615 visits (41.9%), the median examination time after AI Monshin implementation (6.0 minutes, IQR 5.2) was slightly but significantly longer than that before AI Monshin implementation (5.7 minutes, IQR 5.0) (P=.003). Conclusions The implementation of an artificial intelligence–based, automated medical history–taking system did not reduce waiting time for patients visiting the general internal medicine outpatient department without an appointment, and there was a slight increase in the examination time after implementation; however, the system may have enhanced the quality of care by supporting the optimization of staff assignments.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan.,Department of General Internal Medicine, Nagano Chuo Hospital, Nagano, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
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17
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Delshad SD, Almario CV, Chey WD, Spiegel BM. Prevalence of Gastroesophageal Reflux Disease and Proton Pump Inhibitor-Refractory Symptoms. Gastroenterology 2020; 158:1250-1261.e2. [PMID: 31866243 PMCID: PMC7103516 DOI: 10.1053/j.gastro.2019.12.014] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS There are few data on the prevalence of gastroesophageal reflux disease (GERD) in the United States. We performed a population-based study to determine the prevalence of GERD symptoms and persistent GERD symptoms despite use of proton pump inhibitors (PPIs). METHODS We conducted the National Gastrointestinal Survey in 2015 using MyGiHealth, an app that guides participants through National Institutes of Health gastrointestinal Patient-Reported Outcomes Measurement Information System surveys. Primary outcomes were prevalence of GERD symptoms in the past and persistence of GERD symptoms (heartburn or regurgitation 2 or more days in past week) among participants taking PPIs. Population weights were applied to the data and multivariable regression was used to adjust for confounding. RESULTS Among 71,812 participants, 32,878 (44.1%) reported having had GERD symptoms in the past and 23,039 (30.9%) reported having GERD symptoms in the past week. We also found that 35.1% of those who had experienced GERD symptoms were currently on therapy (55.2% on PPIs, 24.3% on histamine-2 receptor blockers, and 24.4% on antacids). Among 3229 participants taking daily PPIs, 54.1% had persistent GERD symptoms. Younger individuals, women, Latino individuals, and participants with irritable bowel syndrome or Crohn's disease were more likely to have continued symptoms, even when taking PPIs. CONCLUSIONS Using a population-based survey, we found GERD symptoms to be common: 2 of 5 participants have had GERD symptoms in the past and 1 of 3 had symptoms in the past week. We also found that half of PPI users have persistent symptoms. Given the significant effect of GERD on quality of life, further research and development of new therapies are needed for patients with PPI-refractory GERD symptoms.
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Affiliation(s)
- Sean D. Delshad
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christopher V. Almario
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI
| | - Brennan M.R. Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA
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18
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Brandberg H, Kahan T, Spaak J, Sundberg K, Koch S, Adeli A, Sundberg CJ, Zakim D. A prospective cohort study of self-reported computerised medical history taking for acute chest pain: protocol of the CLEOS-Chest Pain Danderyd Study (CLEOS-CPDS). BMJ Open 2020; 10:e031871. [PMID: 31969363 PMCID: PMC7044839 DOI: 10.1136/bmjopen-2019-031871] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Management of acute chest pain focuses on diagnosis or safe rule-out of an acute coronary syndrome (ACS). We aim to determine the additional value of self-reported computerised history taking (CHT). METHODS AND ANALYSIS Prospective cohort study design with self-reported, medical histories collected by a CHT programme (Clinical Expert Operating System, CLEOS) using a tablet. Women and men presenting with acute chest pain to the emergency department at Danderyd University Hospital (Stockholm, Sweden) are eligible. CHT will be compared with standard history taking for completeness of data required to calculate ACS risk scores such as History, ECG, Age, Risk factors and Troponin (HEART), Global Registry of Acute Coronary Events (GRACE), and Thrombolysis in Myocardial Infarction (TIMI). Clinical outcomes will be extracted from hospital electronic health records and national registries. The CLEOS-Chest Pain Danderyd Study project includes (1) a feasibility study of CHT, (2) a validation study of CHT as compared with standard history taking, (3) a paired diagnostic accuracy study using data from CHT and established risk scores, (4) a clinical utility study to evaluate the impact of CHT on the management of chest pain and the use of resources, and (5) data mining, aiming to generate an improved risk score for ACS. Primary outcomes will be analysed after 1000 patients, but to allow for subgroup analysis, the study intends to recruit 2000 or more patients. This ongoing project may lead to new and more effective ways for collecting thorough, accurate medical histories with important implications for clinical practice. ETHICS AND DISSEMINATION This study has been reviewed and approved by the Stockholm Regional Ethical Committee (now Swedish Ethical Review Authority). Results will be published, regardless of the outcome, in peer-reviewed international scientific journals. TRIAL REGISTRATION NUMBER This study is registered at https://www.clinicaltrials.gov (unique identifier: NCT03439449).
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Affiliation(s)
- Helge Brandberg
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | - Thomas Kahan
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | - Kay Sundberg
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Sabine Koch
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Athena Adeli
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Carl Johan Sundberg
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - David Zakim
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, and Health Informatics Centre, Karolinska Institutet, Stockholm, Stockholm, Sweden
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Burden of Gastrointestinal Symptoms in the United States: Results of a Nationally Representative Survey of Over 71,000 Americans. Am J Gastroenterol 2018; 113:1701-1710. [PMID: 30323268 PMCID: PMC6453579 DOI: 10.1038/s41395-018-0256-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 07/30/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Digestive diseases account for >100 million ambulatory care visits annually in the U.S. Yet, comparatively less is known about the true burden of gastrointestinal (GI) symptoms in the general U.S. POPULATION The aim of this study was to use data from the "National GI Survey"-a population-based audit of GI symptoms in >71,000 participants-to determine the prevalence and predictors of GI symptoms in community-dwelling Americans. METHODS We conducted the National GI Survey using a mobile app called MyGiHealth, which employs a computer algorithm that systematically collects participants' GI symptoms. We recruited a nationally representative sample of Americans to complete the survey, which guided respondents through National Institutes of Health (NIH) GI Patient Reported Outcome Measurement Information System (PROMIS®) scales along with questions about relevant comorbidities and demographics. We measured the prevalence of GI symptoms in the past week and employed logistic regression to adjust for confounding. RESULTS Overall, 71,812 individuals completed the survey, of which 61% reported having had ≥1 GI symptom in the past week. The most commonly reported symptoms were heartburn/reflux (30.9%), abdominal pain (24.8%), bloating (20.6%), diarrhea (20.2%), and constipation (19.7%). Less common symptoms were nausea/vomiting (9.5%), dysphagia (5.8%), and bowel incontinence (4.8%). Females, non-Hispanic whites, and individuals who were younger, highly educated, and had medical comorbidities were more likely to have symptoms (all adjusted p < 0.05). CONCLUSIONS In this large population-based study that combined digital health technology with NIH PROMIS questionnaires, we found that GI symptoms are highly prevalent, as nearly two thirds of surveyed Americans are burdened by these symptoms.
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Unique Clinical Language Patterns Among Expert Vestibular Providers Can Predict Vestibular Diagnoses. Otol Neurotol 2018; 39:1163-1171. [PMID: 30080764 DOI: 10.1097/mao.0000000000001930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify novel language usage by expert providers predictive of specific vestibular conditions. STUDY DESIGN Retrospective chart review and natural language processing. Level IV. SETTING Tertiary referral center. PATIENTS Patients seen for vestibular complaint. INTERVENTION(S) Natural language processing and machine learning analyses of semantic and syntactic patterns in clinical documentation from vestibular patients. MAIN OUTCOME MEASURE Accuracy of Naïve Bayes predictive models correlating language usage with clinical diagnoses. RESULTS Natural language analyses on 866 physician-generated histories from vestibular patients found 3,286 unique examples of language usage of which 614 were used 10 or greater times. The top 15 semantic types represented only 11% of all Unified Medical Language System semantic types but covered 86% of language used in vestibular patient histories. Naïve Bayes machine learning algorithms on a subset of 255 notes representing benign paroxysmal positional vertigo, vestibular migraine, anxiety-related dizziness and central dizziness generated strong predictive models showing an average sensitivity rate of 93.4% and a specificity rate of 98.2%. A binary model for assessing whether a subject had a specific diagnosis or not had an average AUC for the receiver operating characteristic curves of .995 across all conditions. CONCLUSIONS These results indicate that expert providers utilize unique language patterns in vestibular notes that are highly conserved. These patterns have strong predictive power toward specific vestibular diagnoses. Such language elements can provide a simple vocabulary to aid nonexpert providers in formulating a differential diagnosis. They can also be incorporated into clinical decision support systems to facilitate accurate vestibular diagnosis in ambulatory settings.
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21
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Menees SB, Almario CV, Spiegel BM, Chey WD. Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey. Gastroenterology 2018; 154:1672-1681.e3. [PMID: 29408460 PMCID: PMC6370291 DOI: 10.1053/j.gastro.2018.01.062] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/17/2018] [Accepted: 01/25/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Fecal incontinence (FI) is characterized by uncontrolled passage of solid or liquid stool. We aimed to determine the prevalence and severity of FI in a large sample of US residents. METHODS We recruited a representative sample of patients in October 2015 to complete the National Gastrointestinal (GI) Survey; a mobile app called MyGiHealth was used to systematically collect data on GI symptoms. FI was defined as accidental leakage of solid or liquid stool. Severity of FI was determined by responses to the National Institutes of Health FI Patient Reported Outcomes Measurement Information System questionnaire. Multivariable regression models were used to identify factors associated with FI prevalence and severity. RESULTS Among 71,812 individuals who completed the National GI Survey, 14.4% reported FI in the past; of these, 33.3% had FI within the past 7 days. Older age, male sex, and Hispanic ethnicity increased the likelihood of having FI within the past week. Individuals with Crohn's disease, ulcerative colitis, celiac disease, irritable bowel syndrome, or diabetes were more likely to report FI. Non-Hispanic black and Hispanic individuals and individuals with Crohn's disease, celiac disease, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, or chronic idiopathic constipation had more severe symptoms of FI than individuals without these features. CONCLUSIONS In a large population-based survey, 1 in 7 people reported previous FI. FI is age-related and more prevalent among individuals with inflammatory bowel disease, celiac disease, irritable bowel syndrome, or diabetes than people without these disorders. Proactive screening for FI among these groups is warranted.
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Affiliation(s)
- Stacy B. Menees
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI,Division of Gastroenterology, Department of Internal Medicine, Ann
Arbor Veterans Affairs Medical Center, Ann Arbor, MI
| | - Christopher V. Almario
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE),
Los Angeles, CA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical
Center, Los Angeles, CA,Division of Health Services Research, Cedars-Sinai Medical Center,
Los Angeles, CA,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles,
CA
| | - Brennan M.R. Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE),
Los Angeles, CA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical
Center, Los Angeles, CA,Division of Health Services Research, Cedars-Sinai Medical Center,
Los Angeles, CA,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles,
CA
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI
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22
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Shah ED, Almario CV, Spiegel BMR, Chey WD. Lower and Upper Gastrointestinal Symptoms Differ Between Individuals With Irritable Bowel Syndrome With Constipation or Chronic Idiopathic Constipation. J Neurogastroenterol Motil 2018; 24:299-306. [PMID: 29605985 PMCID: PMC5885729 DOI: 10.5056/jnm17112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/09/2017] [Accepted: 01/21/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS We evaluated the distribution of lower and upper gastrointestinal (GI) symptoms among individuals with irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in a nationwide survey. METHODS Individuals (≥ 18 years of age) were identified from a nationwide sample of > 70 000 United States adults. Participants completed the National Institutes of Health GI Patient Reported Outcomes Measurement Information System (NIH GI-PROMIS) questionnaire. Symptom frequency and intensity in the prior 7 days were assessed using validated PROMIS scores. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to compare symptom prevalence in IBS-C vs CIC, and one-way ANOVA was used to assess differences in PROMIS scores. Regression analysis was performed to adjust for demographic variables. RESULTS Nine hundred and seventy adults met eligibility criteria (275 with IBS-C, 734 with CIC). Demographics were similar among groups except for education, marital and employment status, and income. Adjusting for demographic differences, GI-PROMIS scores of global GI symptoms were higher in IBS-C (251.1; 95% CI, 230.0-273.1) compared to CIC (177.8; 95% CI 167.2-188.4) (P < 0.001). Abdominal pain was more prevalent (OR, 4.3; 95% CI, 2.9-6.6) and more severe (P = 0.007) in IBS-C. Constipation was more severe in IBS-C (P = 0.011). Incontinence was more common (OR, 2.9; 95% CI, 1.3-6.3) but just as severe (P = 0.389) in IBS-C versus CIC. Regarding upper GI symptoms, the prevalence of dysphagia, heartburn, and nausea were similar. However, IBS-C individuals had more severe heartburn (P = 0.001). CONCLUSION GI symptoms are generally more severe in IBS-C compared to CIC, however abdominal pain, bloating, and upper GI symptoms still commonly occur in CIC.
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Affiliation(s)
- Eric D Shah
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan,
USA
| | - Christopher V Almario
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California,
USA
| | - Brennan M R Spiegel
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California,
USA
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan,
USA
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23
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Zeman JE, Moon PS, McMahon MJ, Holley AB. Developing a Mobile Health Application to Assist With Clinic Flow, Documentation, Billing, and Research in a Specialty Clinic. Chest 2018; 154:440-447. [PMID: 29689261 DOI: 10.1016/j.chest.2018.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 02/28/2018] [Accepted: 04/05/2018] [Indexed: 12/17/2022] Open
Abstract
In specialty clinics, a staff physician is often required to direct patient flow through the clinic and performs all documentation for coding/billing. In response to the workload created by increased patient volume, many specialty clinics have implemented protocols for both disease treatment and coordination of clinic flow. In this article, we review the literature on using mobile technology to assist with patient care, clinic flow, disease treatment, and documentation/billing. We also describe the development and implementation of a mobile application in our pulmonary clinic designed to automate patient flow, assist the physician in documentation/billing, and gather research data including review of initial user data and lessons learned.
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Affiliation(s)
- Joseph E Zeman
- Walter Reed National Military Medical Center, Bethesda, MD.
| | - Patrick S Moon
- Walter Reed National Military Medical Center, Bethesda, MD
| | | | - Aaron B Holley
- Walter Reed National Military Medical Center, Bethesda, MD
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24
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Cong Y, Hart BJ, Gross R, Zhou H, Frieman M, Bollinger L, Wada J, Hensley LE, Jahrling PB, Dyall J, Holbrook MR. MERS-CoV pathogenesis and antiviral efficacy of licensed drugs in human monocyte-derived antigen-presenting cells. PLoS One 2018; 13:e0194868. [PMID: 29566060 PMCID: PMC5864050 DOI: 10.1371/journal.pone.0194868] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/12/2018] [Indexed: 12/21/2022] Open
Abstract
Middle East respiratory syndrome coronavirus (MERS-CoV) presents an emerging threat to public health worldwide by causing severe respiratory disease in humans with high virulence and case fatality rate (about 35%) since 2012. Little is known about the pathogenesis and innate antiviral response in primary human monocyte-derived macrophages (MDMs) and dendritic cells (MDDCs) upon MERS-CoV infection. In this study, we assessed MERS-CoV replication as well as induction of inflammatory cytokines and chemokines in MDMs and immature and mature MDDCs. Immature MDDCs and MDMs were permissive for MERS-CoV infection, while mature MDDCs were not, with stimulation of proinflammatory cytokine and chemokine upregulation in MDMs, but not in MDDCs. To further evaluate the antiviral activity of well-defined drugs in primary antigen presenting cells (APCs), three compounds (chloroquine, chlorpromazine and toremifine), each with broad-spectrum antiviral activity in immortalized cell lines, were evaluated in MDMs and MDDCs to determine their antiviral effect on MERS-CoV infection. While chloroquine was not active in these primary cells, chlorpromazine showed strong anti-MERS-CoV activity, but it was associated with high cytotoxicity narrowing the potential window for drug utilization. Unlike in established cells, toremifene had marginal activity when tested in antigen presenting cells, with high apparent cytotoxicity, also limiting its potential as a therapeutic option. These results demonstrate the value of testing drugs in primary cells, in addition to established cell lines, before initiating preclinical or clinical studies for MERS treatment and the importance of carefully assessing cytotoxicity in drug screen assays. Furthermore, these studies also highlight the role of APCs in stimulating a robust protective immune response to MERS-CoV infection.
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Affiliation(s)
- Yu Cong
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Brit J. Hart
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Robin Gross
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Huanying Zhou
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Matthew Frieman
- Department of Microbiology and Immunology, The University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Laura Bollinger
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Jiro Wada
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Lisa E. Hensley
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Peter B. Jahrling
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
- Emerging Viral Pathogen Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Julie Dyall
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
| | - Michael R. Holbrook
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Ft. Detrick, Frederick, Maryland, United States of America
- * E-mail:
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25
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Almario CV, Almario AA, Cunningham ME, Fouladian J, Spiegel BMR. Old Farts - Fact or Fiction? Results From a Population-Based Survey of 16,000 Americans Examining the Association Between Age and Flatus. Clin Gastroenterol Hepatol 2017; 15:1308-1310. [PMID: 28344066 DOI: 10.1016/j.cgh.2017.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/10/2017] [Accepted: 03/18/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Christopher V Almario
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California; Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California; Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
| | - Alison A Almario
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Joshua Fouladian
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
| | - Brennan M R Spiegel
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California; Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California; Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California.
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26
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Almario CV. The Effect of Digital Health Technology on Patient Care and Research. Gastroenterol Hepatol (N Y) 2017; 13:437-439. [PMID: 28867974 PMCID: PMC5572976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Christopher V Almario
- Assistant Professor of Medicine Division of Digestive and Liver Diseases Cedars-Sinai Medical Center Health Services Research Scientist Cedars-Sinai Center for Outcomes Research and Education (CS-CORE) Los Angeles, California
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27
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Hagaman DH, Ehrenfeld JM, Terekhov M, Kla KM, Hamm J, Brumley M, Wanderer JP. Compliance Is Contagious: Using Informatics Methods to Measure the Spread of a Documentation Standard From a Preoperative Clinic. J Perianesth Nurs 2017; 33:436-443. [PMID: 30077286 DOI: 10.1016/j.jopan.2016.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Preoperative documentation is essential to coordinated care and has the potential for standardization, which may facilitate downstream clinical management. DESIGN An observational pre/post standardization design was used. METHODS We analyzed the implementation of a preoperative documentation standardization intervention in Vanderbilt's Preoperative Evaluation Clinic (VPEC) and its impact outside VPEC. A phased intervention consisted of clinician education with monthly feedback, followed by the development of a compliance dashboard and inclusion in Ongoing Professional Performance Evaluation system by VPEC. A follow-up survey was administered to measure the impact on clinical management. FINDINGS Adherence to standardization was improved with the addition of electronic feedback. Implementation of this system in the preoperative clinic had significant impact outside VPEC. Trainee status was a significant predictor of adoption of the standardized format. CONCLUSIONS Adoption of a preoperative documentation standard in a clinic had a positive impact on standardization practices in a perioperative system.
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Gross-Schulman S, Sklaroff LM, Hertz CC, Guterman JJ. Safety Evaluation of an Automated Remote Monitoring System for Heart Failure in an Urban, Indigent Population. Popul Health Manag 2017; 20:449-457. [PMID: 28486027 DOI: 10.1089/pop.2016.0186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Heart Failure (HF) is the most expensive preventable condition, regardless of patient ethnicity, race, socioeconomic status, sex, and insurance status. Remote telemonitoring with timely outpatient care can significantly reduce avoidable HF hospitalizations. Human outreach, the traditional method used for remote monitoring, is effective but costly. Automated systems can potentially provide positive clinical, fiscal, and satisfaction outcomes in chronic disease monitoring. The authors implemented a telephonic HF automated remote monitoring system that utilizes deterministic decision tree logic to identify patients who are at risk of clinical decompensation. This safety study evaluated the degree of clinical concordance between the automated system and traditional human monitoring. This study focused on a broad underserved population and demonstrated a safe, reliable, and inexpensive method of monitoring patients with HF.
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Affiliation(s)
| | - Laura Myerchin Sklaroff
- 1 Los Angeles County Department of Health Services , Los Angeles, California.,2 College of Behavioral and Social Sciences, California State University , Northridge, California
| | | | - Jeffrey J Guterman
- 1 Los Angeles County Department of Health Services , Los Angeles, California.,4 David Geffen School of Medicine at UCLA , Los Angeles, California
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29
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Almario CV, Chey WD, Khanna D, Mosadeghi S, Ahmed S, Afghani E, Whitman C, Fuller G, Reid M, Bolus R, Dennis B, Encarnacion R, Martinez B, Soares J, Modi R, Agarwal N, Lee A, Kubomoto S, Sharma G, Bolus S, Spiegel BM. Impact of National Institutes of Health Gastrointestinal PROMIS Measures in Clinical Practice: Results of a Multicenter Controlled Trial. Am J Gastroenterol 2016; 111:1546-1556. [PMID: 27481311 PMCID: PMC5097031 DOI: 10.1038/ajg.2016.305] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/02/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The National Institutes of Health (NIH) created the Patient Reported Outcomes Measurement Information System (PROMIS) to allow efficient, online measurement of patient-reported outcomes (PROs), but it remains untested whether PROMIS improves outcomes. Here, we aimed to compare the impact of gastrointestinal (GI) PROMIS measures vs. usual care on patient outcomes. METHODS We performed a pragmatic clinical trial with an off-on study design alternating weekly between intervention (GI PROMIS) and control arms at one Veterans Affairs and three university-affiliated specialty clinics. Adults with GI symptoms were eligible. Intervention patients completed GI PROMIS symptom questionnaires on an e-portal 1 week before their visit; PROs were available for review by patients and their providers before and during the clinic visit. Usual care patients were managed according to customary practices. Our primary outcome was patient satisfaction as determined by the Consumer Assessment of Healthcare Providers and Systems questionnaire. Secondary outcomes included provider interpersonal skills (Doctors' Interpersonal Skills Questionnaire (DISQ)) and shared decision-making (9-item Shared Decision Making Questionnaire (SDM-Q-9)). RESULTS There were 217 and 154 patients in the GI PROMIS and control arms, respectively. Patient satisfaction was similar between groups (P>0.05). Intervention patients had similar assessments of their providers' interpersonal skills (DISQ 89.4±11.7 vs. 89.8±16.0, P=0.79) and shared decision-making (SDM-Q-9 79.3±12.4 vs. 79.0±22.0, P=0.85) vs. CONCLUSIONS This is the first controlled trial examining the impact of NIH PROMIS in clinical practice. One-time use of GI PROMIS did not improve patient satisfaction or assessment of provider interpersonal skills and shared decision-making. Future studies examining how to optimize PROs in clinical practice are encouraged before widespread adoption.
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Affiliation(s)
- Christopher V. Almario
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA,Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - William D. Chey
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI
| | - Sasan Mosadeghi
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Shahzad Ahmed
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Elham Afghani
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Cynthia Whitman
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Garth Fuller
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Mark Reid
- Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Roger Bolus
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Buddy Dennis
- UCLA Computing Technology Research Laboratory (CTRL), Los Angeles, CA
| | - Rey Encarnacion
- UCLA Computing Technology Research Laboratory (CTRL), Los Angeles, CA
| | - Bibiana Martinez
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA,Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Jennifer Soares
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA,Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Rushaba Modi
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Nikhil Agarwal
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Aaron Lee
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Scott Kubomoto
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Gobind Sharma
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Sally Bolus
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Brennan M.R. Spiegel
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA,Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
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Zakim D. Development and significance of automated history-taking software for clinical medicine, clinical research and basic medical science. J Intern Med 2016; 280:287-99. [PMID: 27071980 DOI: 10.1111/joim.12509] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- D Zakim
- Unit for Bioentrepreneurship (UBE), Medical Management Centre at the Department of Learning Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
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31
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Spiegel B. 2015 American Journal of Gastroenterology Lecture: How Digital Health Will Transform Gastroenterology. Am J Gastroenterol 2016; 111:624-30. [PMID: 27045930 DOI: 10.1038/ajg.2016.68] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
Our patients spend most of their lives far away from an examination room. If we are truly going to capture our patients' attention and engage them in their care, then we must reach beyond the four walls of the clinic, hospital, or endoscopy suite. This is the vision of the digital health movement-an effort to monitor patients remotely and dynamically with mobile health ("mHealth") smartphone applications, electronic health record portals, social media, and wearable biosensors to improve health care outside of the clinical trenches. This article explores how advances in digital health may improve health-care delivery, focusing on gastroenterology and hepatology. It describes how technology can monitor patients remotely, improve face-to-face care, drive clinical decisions, and offer value to health-care organizations, their patients, and their staff. The article also describes pitfalls and shortcomings of digital technologies and concludes by describing a new model for how digital health can be deployed at scale to improve coordination and outcomes of care.
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Affiliation(s)
- Brennan Spiegel
- Department of Medicine, Division of Health Services Research, Cedars-Sinai Health System, Los Angeles, California, USA.,UCLA Fielding School of Public Health, Los Angeles, California, USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California, USA
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Almario CV, Chey WD, Iriana S, Dailey F, Robbins K, Patel AV, Reid M, Whitman C, Fuller G, Bolus R, Dennis B, Encarnacion R, Martinez B, Soares J, Modi R, Agarwal N, Lee A, Kubomoto S, Sharma G, Bolus S, Chang L, Spiegel BMR. Computer versus physician identification of gastrointestinal alarm features. Int J Med Inform 2015; 84:1111-7. [PMID: 26254875 DOI: 10.1016/j.ijmedinf.2015.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE It is important for clinicians to inquire about "alarm features" as it may identify those at risk for organic disease and who require additional diagnostic workup. We developed a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS) that systematically collects patient gastrointestinal (GI) symptoms and alarm features, and then "translates" the information into a history of present illness (HPI). Our study's objective was to compare the number of alarms documented by physicians during usual care vs. that collected by AEGIS. METHODS We performed a cross-sectional study with a paired sample design among patients visiting adult GI clinics. Participants first received usual care by their physicians and then completed AEGIS. Each individual thus contributed both a physician-documented and computer-generated HPI. Blinded physician reviewers enumerated the positive alarm features (hematochezia, melena, hematemesis, unintentional weight loss, decreased appetite, and fevers) mentioned in each HPI. We compared the number of documented alarms within patient using the Wilcoxon signed-rank test. RESULTS Seventy-five patients had both physician and AEGIS HPIs. AEGIS identified more patients with positive alarm features compared to physicians (53% vs. 27%; p<.001). AEGIS also documented more positive alarms (median 1, interquartile range [IQR] 0-2) vs. physicians (median 0, IQR 0-1; p<.001). Moreover, clinicians documented only 30% of the positive alarms self-reported by patients through AEGIS. CONCLUSIONS Physicians documented less than one-third of red flags reported by patients through a computer algorithm. These data indicate that physicians may under report alarm features and that computerized "checklists" could complement standard HPIs to bolster clinical care.
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Affiliation(s)
- Christopher V Almario
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of Digestive Diseases, UCLA, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Sentia Iriana
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Francis Dailey
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Karen Robbins
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anish V Patel
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Reid
- Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Cynthia Whitman
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Garth Fuller
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Roger Bolus
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Buddy Dennis
- UCLA Computing Technology Research Laboratory (CTRL), Los Angeles, CA, USA
| | - Rey Encarnacion
- UCLA Computing Technology Research Laboratory (CTRL), Los Angeles, CA, USA
| | - Bibiana Martinez
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Jennifer Soares
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Rushaba Modi
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of Digestive Diseases, UCLA, Los Angeles, CA, USA
| | - Nikhil Agarwal
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of Digestive Diseases, UCLA, Los Angeles, CA, USA
| | - Aaron Lee
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Scott Kubomoto
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gobind Sharma
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sally Bolus
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Lin Chang
- Division of Digestive Diseases, UCLA, Los Angeles, CA, USA
| | - Brennan M R Spiegel
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA.
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