Computer Patient Interviewing: Instant Medical History & UK Experience

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

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

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

4. Let's look at some history #DHOx

5. Anyone recognise this man? #DHOx

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

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

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

9. “Toward Automating the Medical History” “...to relieve the physician from routine, although important, time‑consuming activities, thereby extending his capabilities to provide medical care. If the time physicians spend in collecting, organizing, recording, and retrieving data could be reduced, at least in part, by information technology, more time would be available for actual delivery of medical care and at the same time the physician’s capabilities for collecting information from patients would be extended...” by Mayne, Weksel, and Sholz When was this published? 2007? #DHOx

15. “Toward Automating the Medical History” “...to relieve the physician from routine, although important, time‑consuming activities, thereby extending his capabilities to provide medical care. If the time physicians spend in collecting, organizing, recording, and retrieving data could be reduced, at least in part, by information technology, more time would be available for actual delivery of medical care and at the same time the physician’s capabilities for collecting information from patients would be extended...” by Mayne, Weksel, and Sholz When was this published? Before 1969? #DHOx

16. “Toward Automating the Medical History” “...to relieve the physician from routine, although important, time‑consuming activities, thereby extending his capabilities to provide medical care. If the time physicians spend in collecting, organizing, recording, and retrieving data could be reduced, at least in part, by information technology, more time would be available for actual delivery of medical care and at the same time the physician’s capabilities for collecting information from patients would be extended...” by Mayne, Weksel, and Sholz (1968) #DHOx

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

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

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

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

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

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

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

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

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

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

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

28. History taking: how does the Computer Perform? #DHOx

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

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

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

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

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

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

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

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

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

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

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

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

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

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

43. Instant Medical History: UK Experience Proof of Concept: http://www.htmc.co.uk/pages/pv.asp?p=htmc0473 @AmirHannan #DHOx

44. #DHOx Instant Medical History: UK Experience An implementation: 3GDoctor.com #DHOx

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

46. Instant Medical History: UK Experience An implementation: AskMyGP .UK #DHOx

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

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

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

50. Demand follows predictable daily pattern, high Mondays, low weekends

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

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

53. 73% of Patients want help from anyone, 27% request named GP 10% want most popular GP.

54. 5,000 symptoms entered resolve into 320 different groups (and counting)

55. Top 10, Family Practice, Peterborough

56. Children under 5, North London

57. Adults aged 20-60, Deprived Area, Scotland

58. 87% presented with single problem. 13% presented with more than one problem.

59. 50% of demand is a new problem, 21% is follow up 29% an existing condition.

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

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

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

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

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

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

66. How AskMyGP works as a system

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

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

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

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

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

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

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

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

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