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Computer Patient Interviewing
& Pilot Medical Assessment
Dr Richard Sills
rosills1@gmail.com #ICASM2015
Acklowledgements & Declarations
#ICASM2015
The AAME (UK) Has kindly contributed towards my
attendance at the conference
I ...
Why particularly relevant
#ICASM2015
Recent tragic events
Need to improve Psychological Assessment
Need to be seen to be i...
From this conference
#ICASM2015
Significant under reporting of psychological symtpoms and
sub-optimal documentation
Diffic...
Anyone recognise this man?
#ICASM2015
A Canadian Physician, one of the four
founding Professors of John Hopkins
Hospital, ...
Sir William Osler (1849-1919)
#ICASM2015
“Talk to the Patient long enough
& he will tell you what is wrong
with him”
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
“Toward Automating
the Medical History”
#ICASM2015
“...to relieve the physician from routine, although
important, time‑con...
Important reviews
#ICASM2015
Jones RB, Knill-Jones RP. Electronic Patient Record
Project: Direct Patient Input to the Reco...
Highlights
#ICASM2015
Warner Slack paper 1960’s
Ray Jones paper 1990’s
Pringle, BMJ 1988
Prof Bachman literature review 20...
Common conclusions
#ICASM2015
“A well designed computer system can be used
to interview patients about their medical histo...
From 1968
#ICASM2015
“A branching series of questions is developed to
assist the medical history taking of the clinician.
...
Professor Ray Jones
#ICASM2015
From the number of published research studies in
which computers have been successfully use...
Dr M Pringle
#ICASM2015
“Computers may be used acceptably to gather
accurate information and to improve medical
decisions ...
Professor John Bachman MD
#ICASM2015
“Computer Patient Interviewing is valid”
“Instant Medical History is the World leader...
Can a computer take a Psychiatric History?
#ICASM2015
“A program on an inexpensive microcomputer was designed to elicit
pe...
Comparison of computer-based & personal interviews
#ICASM2015
“A computer-based questionnaire can generate responses that ...
Mayo Clinic eVisits 2010
#ICASM2015
“The e-visits made surgery visits unnecessary in 1012
cases (40%)”
“In the basic e-vis...
History taking: How do we perform?
#ICASM2015
Physicians miss 54% of patients problems and
45% of their concerns
In 50% of...
History taking: how does the
Computer Perform?
#ICASM2015
Strengths of Computerised interview
#ICASM2015
Structured, all questions are asked
Does not Interrupt
Good at obtaining se...
Strengths of Computerised interview
#ICASM2015
All questions usually answered
Can be done anywhere, at Patient’s pace
& wi...
Patient can complete as little or
as much as they feel able and the
depth of questioning can be tailored
to suit the clini...
Computers show no embarrassment
in asking important questions where
responses deem that question is
worth answering
Otolarngology
History of Ear surgery for infection
Accidents and Injuries
History of Concussion. Bone fracture. Post head ...
Otolarngology
History of Ear surgery for infection
Accidents and Injuries
History of Concussion. Bone fracture. Post head ...
Psychiatric
Anxiety Disorders
He reported: Stress now.
Risk Factors, Prevention and Patient issues
Prevention
Counselling
...
Psychiatric
Anxiety Disorders
He reported: Stress now.
Risk Factors, Prevention and Patient issues
Prevention
Counselling
...
Chief Complaint
E M is a 11 year old male. His reason for visit is “12 year old check-up”
Past, Family, and Social History...
Chief Complaint
E M is a 11 year old male. His reason for visit is “12 year old check-up”
Past, Family, and Social History...
Chief Complaint
A M is a 13 year old male. His reason for visit is “Pre-Participation Sports Exam”
Past, Family, and Socia...
Chief Complaint
A M is a 13 year old male. His reason for visit is “Pre-Participation Sports Exam”
Past, Family, and Socia...
She denied pressure or pain in chest, heart murmur, intermittent chest pain, heavy squeezing tight chest
pressure, edema, ...
She denied pressure or pain in chest, heart murmur, intermittent chest pain, heavy squeezing tight chest
pressure, edema, ...
Patients collect info that Clinicians miss
#ICASM2015
40% of the time the questionnaire provided
useful information that w...
Relevance to Pilot Assessment
#ICASM2015
Psychological issues
Illicit Drugs
Alcohol
Documentation
Evidence strongly sugges...
Completeness
#ICASM2015
CPI ensures that lines of investigation are not forgotten, leading to more
complete data and fewer...
Alcohol
#ICASM2015
Alcoholic Captain
“Wanted to be caught”
Wasn’t asked the right questions
CPI would have asked
Let Pilots do the work
#ICASM2015
The use of Computer Patient Interviewing allows pilots
to give a very full history whils...
Outcomes of using CPI
#ICASM2015
More complete questioning.
Better documentation which in turn will enhance the
ability to...
Change Management in Healthcare
#ICASM2015
“That the stethoscope will ever come into general use,
notwithstanding its valu...
Thank you for your interest
#ICASM2015
Dr Richard Sills
rosills1@gmail.com
+44 (0) 7940836337
slideshare.net/ICASM2015
(If...
https://www.youtube.com/watch?v=uY32p_BqPw0
“Yes, yes, Mrs Jones... ...we'll talk about your chest pain in one
minute. Right now I'm just trying to remember my passwo...
A machine cannot come between
me and my Patient!
#ICASM2015
All of this is true
It need not happen
A case (thanks to Prof Bachman)
#ICASM2015
A patient who has hypertension comes to see you
because in the last ten days sh...
Chief Complaint Time/Date
Sonk is a 65 year old female. Her reason for visit is “Hypertension” 13:34pm. April 17, 2003
His...
A case (thanks to Prof Bachman)
#ICASM2015
WHAT A DOC!!!!!
1) Her B/P is coming down: 138/80 and now 128/78
2) Her “numb f...
What can we learn from this?
#ICASM2015
We can not judge quality of care by reviewing
a chart!
Inputs are important
Comput...
Embarrassing Topics
#ICASM2015
CPI allows patients to more easily disclose information
about embarrassing topics eg. compu...
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Computer Patient Interviewing & Pilot Medical Assessment #ICASM2015

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Slides to accompany talk given by Dr Richard Sills on Wednesday 23rd September 2015 at the 63rd International Congress of Aviation and Space Medicine, held at Oxford University (UK).

http://icasm2015.org/

For more information on Instant Medical History and adding Computer Patient Interviewing to Pilot Medical Assessments please visit MedicalHistory.com and contact Richard Sills at rosills1@gmail.com

Published in: Health & Medicine
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Computer Patient Interviewing & Pilot Medical Assessment #ICASM2015

  1. 1. Computer Patient Interviewing & Pilot Medical Assessment Dr Richard Sills rosills1@gmail.com #ICASM2015
  2. 2. Acklowledgements & Declarations #ICASM2015 The AAME (UK) Has kindly contributed towards my attendance at the conference 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
  3. 3. Why particularly relevant #ICASM2015 Recent tragic events Need to improve Psychological Assessment Need to be seen to be improving Psychological Assessment Need to improve efficiency of Aeromedical Assessment and Documentation
  4. 4. From this conference #ICASM2015 Significant under reporting of psychological symtpoms and sub-optimal documentation Difficulty of persuading pilots to part with information Need to ask specific questions
  5. 5. Anyone recognise this man? #ICASM2015 A Canadian Physician, one of the four founding Professors of John Hopkins Hospital, he is described as the "Father of Modern Medicine".
  6. 6. Sir William Osler (1849-1919) #ICASM2015 “Talk to the Patient long enough & he will tell you what is wrong with him”
  7. 7. “Toward Automating the Medical History” #ICASM2015 “...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
  8. 8. “Toward Automating the Medical History” #ICASM2015 “...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?
  9. 9. “Toward Automating the Medical History” #ICASM2015 “...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? 2004?
  10. 10. “Toward Automating the Medical History” #ICASM2015 “...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? 1996?
  11. 11. “Toward Automating the Medical History” #ICASM2015 “...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? 1989?
  12. 12. “Toward Automating the Medical History” #ICASM2015 “...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? 1988?
  13. 13. “Toward Automating the Medical History” #ICASM2015 “...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? 1979?
  14. 14. “Toward Automating the Medical History” #ICASM2015 “...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?
  15. 15. “Toward Automating the Medical History” #ICASM2015 “...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)
  16. 16. Important reviews #ICASM2015 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.
  17. 17. Highlights #ICASM2015 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
  18. 18. Common conclusions #ICASM2015 “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”
  19. 19. From 1968 #ICASM2015 “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”
  20. 20. Professor Ray Jones #ICASM2015 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
  21. 21. Dr M Pringle #ICASM2015 “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
  22. 22. Professor John Bachman MD #ICASM2015 “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.
  23. 23. Can a computer take a Psychiatric History? #ICASM2015 “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.
  24. 24. Comparison of computer-based & personal interviews #ICASM2015 “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.
  25. 25. Mayo Clinic eVisits 2010 #ICASM2015 “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
  26. 26. History taking: How do we perform? #ICASM2015 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)
  27. 27. History taking: how does the Computer Perform? #ICASM2015
  28. 28. Strengths of Computerised interview #ICASM2015 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
  29. 29. Strengths of Computerised interview #ICASM2015 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
  30. 30. 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
  31. 31. Computers show no embarrassment in asking important questions where responses deem that question is worth answering
  32. 32. Otolarngology 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. Cervical 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
  33. 33. Otolarngology 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. Cervical 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
  34. 34. Psychiatric Anxiety Disorders He reported: Stress now. Risk Factors, Prevention and Patient issues Prevention Counselling He reported: Not wearing protective eye. Carried weapon 6 or more days last month. Nutrition He reported Diet in last month Patient Issues He reported: Consulting another physician Self-assessment Scales Title: Asthma Control Test Description: 5-item scale to determine problems with asthma in the last month. Patient Score 20 – Asthma may be under control Scoring Key and Interpretation: 0-19 : Asthma not well controlled 20-25 : Asthma may be under control Reference: Nathan RA, Sorkness CA, Kosinski M, et al. Development of the Asthma Control Test a survey for assessing asthma control J Allergy Clin Immunol 2004,113 59-65 Title: Mental Health Inventory Screening Test (MHI-5) Description: Short 5-item version of the 18 item Mental Health Inventory for detecting affective disorders. No level of severity is revealed because of the brevity of the scale. Patient Score 9 – Passed mental health screen Scoring Key and Interpretation: 0-17 : Passed mental health screen 18-30 : Failed mental health screen Reference: Berwick, DM, Murphy, JM Goldman, PA, “Performance of a Five item Mentla Health Screening Test”, Med Care 1991, 29,2 169-176. Title: Children of Alcoholics Screening Test (CAST) Description: 30-item inventory identifies children and adolescents who are living with at least one alcoholic parent. It measures children's feelings, attitudes, perceptions and experiences related to their parents' drinking behaviour. It reliably identified 100% of the children or both clinically diagnosed and self-reported alcoholics. Patient Score 11 – Severe family dysfunction due to alcoholism Scoring Key and Interpretation: 0-3 : Non-alcoholic family 4-9 : Family problem with alcholism likely 10-30: Severe family dysfunction due to alcoholism Reference: Jones JW Chilren of Alcoholics Screening Test, (CAST) Chicago, III Camelot Unlimited 1983
  35. 35. Psychiatric Anxiety Disorders He reported: Stress now. Risk Factors, Prevention and Patient issues Prevention Counselling He reported: Not wearing protective eye. Carried weapon 6 or more days last month. Nutrition He reported Diet in last month Patient Issues He reported: Consulting another physician Self-assessment Scales Title: Asthma Control Test Description: 5-item scale to determine problems with asthma in the last month. Patient Score 20 – Asthma may be under control Scoring Key and Interpretation: 0-19 : Asthma not well controlled 20-25 : Asthma may be under control Reference: Nathan RA, Sorkness CA, Kosinski M, et al. Development of the Asthma Control Test a survey for assessing asthma control J Allergy Clin Immunol 2004,113 59-65 Title: Mental Health Inventory Screening Test (MHI-5) Description: Short 5-item version of the 18 item Mental Health Inventory for detecting affective disorders. No level of severity is revealed because of the brevity of the scale. Patient Score 9 – Passed mental health screen Scoring Key and Interpretation: 0-17 : Passed mental health screen 18-30 : Failed mental health screen Reference: Berwick, DM, Murphy, JM Goldman, PA, “Performance of a Five item Mentla Health Screening Test”, Med Care 1991, 29,2 169-176. Title: Children of Alcoholics Screening Test (CAST) Description: 30-item inventory identifies children and adolescents who are living with at least one alcoholic parent. It measures children's feelings, attitudes, perceptions and experiences related to their parents' drinking behaviour. It reliably identified 100% of the children or both clinically diagnosed and self-reported alcoholics. Patient Score 11 – Severe family dysfunction due to alcoholism Scoring Key and Interpretation: 0-3 : Non-alcoholic family 4-9 : Family problem with alcholism likely 10-30: Severe family dysfunction due to alcoholism Reference: Jones JW Chilren of Alcoholics Screening Test, (CAST) Chicago, III Camelot Unlimited 1983
  36. 36. Chief Complaint E M is a 11 year old male. His reason for visit is “12 year old check-up” Past, Family, and Social History Social History History of: Within the last six months changing schools. Within the last two years marriage of a family member, gaining of a family member, and change in the health of a family member. Lives with parents. Sexual History History of Slight concerns with HIV infection. Review of Systems Musculoskeletal He reported: Back pain sometimes Neurologic He reported: Headaches once a week. Dyssomnia. Risk Factors, Prevention, and Patient Issues Prevention Counseling He reported: Does not use bike safety helmet. Nutrition He reported 1-2 servings of fruit daily. 1-2 servings of vegtables daily. Desiring to be thinner. cial History Self-assessment Scales Title: SCOFF Description: Brief 5-question screening tool for eating disorders. Patient Score 0 – Normal eating, no indication of anorexia nervosa or bulimia Scoring Key and Interpretation: 0-1 : Normal eating, no indication of anorexia nervosa or bulimia 2-5 : Abnormal eating, likely indication of anorexia nervosa or bulimia Reference: Morgan JF, Reid F, Lacey JH. The SCOFF questionniare assessment of a new screening tool for eating disorders.. British Medical Journal 1999, 319-1467
  37. 37. Chief Complaint E M is a 11 year old male. His reason for visit is “12 year old check-up” Past, Family, and Social History Social History History of: Within the last six months changing schools. Within the last two years marriage of a family member, gaining of a family member, and change in the health of a family member. Lives with parents. Sexual History History of Slight concerns with HIV infection. Review of Systems Musculoskeletal He reported: Back pain sometimes Neurologic He reported: Headaches once a week. Dyssomnia. Risk Factors, Prevention, and Patient Issues Prevention Counseling He reported: Does not use bike safety helmet. Nutrition He reported 1-2 servings of fruit daily. 1-2 servings of vegtables daily. Desiring to be thinner. cial History Self-assessment Scales Title: SCOFF Description: Brief 5-question screening tool for eating disorders. Patient Score 0 – Normal eating, no indication of anorexia nervosa or bulimia Scoring Key and Interpretation: 0-1 : Normal eating, no indication of anorexia nervosa or bulimia 2-5 : Abnormal eating, likely indication of anorexia nervosa or bulimia Reference: Morgan JF, Reid F, Lacey JH. The SCOFF questionniare assessment of a new screening tool for eating disorders.. British Medical Journal 1999, 319-1467
  38. 38. Chief Complaint A M is a 13 year old male. His reason for visit is “Pre-Participation Sports Exam” Past, Family, and Social History Accidents and injuries History of: Concussion. Injury torn ligaments. Head injury. Doesn't know number of leg torn ligaments. Doesn't know which bones were broken in lower leg. Head laceration. Family History Mother History of: Asthma Social History History of: Physical assualt less than 2 monhts ago and by unknown person Allergy History History of: No allergies to medicines, pollen, foods or stinging insects Prior Available Tests History of: Previous evaluation included an X-Ray of the shoulder. Treatment for musculoskeletal injury. Doesn't know number of leg X-Rays. Doesn't know number of arm X-Rays. Review of Systems Eye He reported: Vision change Neurologic He reported: Paresthesia post traumatic. Paralysis post traumatic. Headaches sometimes precipitated or aggravated by exertion. Risk Factors, Prevention, and Patient Issues Prevention Counseling He reported: Not weating protective eyewear Time/Date 10:16am August 6 2010
  39. 39. Chief Complaint A M is a 13 year old male. His reason for visit is “Pre-Participation Sports Exam” Past, Family, and Social History Accidents and injuries History of: Concussion. Injury torn ligaments. Head injury. Doesn't know number of leg torn ligaments. Doesn't know which bones were broken in lower leg. Head laceration. Family History Mother History of: Asthma Social History History of: Physical assualt less than 2 monhts ago and by unknown person Allergy History History of: No allergies to medicines, pollen, foods or stinging insects Prior Available Tests History of: Previous evaluation included an X-Ray of the shoulder. Treatment for musculoskeletal injury. Doesn't know number of leg X-Rays. Doesn't know number of arm X-Rays. Review of Systems Eye He reported: Vision change Neurologic He reported: Paresthesia post traumatic. Paralysis post traumatic. Headaches sometimes precipitated or aggravated by exertion. Risk Factors, Prevention, and Patient Issues Prevention Counseling He reported: Not weating protective eyewear Time/Date 10:16am August 6 2010
  40. 40. She denied pressure or pain in chest, heart murmur, intermittent chest pain, heavy squeezing tight chest pressure, edema, varicose veins, claudication. Gastrointestinal She denied gastrointestinal symptoms, nausea, diarrhea, constipation, change in bowel habits, yellow rash. Genitourinary She denied genitourinary symptoms, dysuria, vaginal discharge. Endocrine She denied gland trouble, diabetesm goutm or thyroid condition, change in thirst or appetite. Hematological Muskuloskeletal She denied excessive bleeding, swollen glands She denied rheumatic symptoms, swelling of extremities. Neurologial She reported frequent headaches, headaches more than twice a month, headache similar to previous headaches, onset of headaches under age of 24. She denied motor disturbances, dyssomnia, headaches usually periorbital at onset, periauricular headaches associated with opening jaw, headaches cause awakening from sleep, headaches more frequent certain days of the week, headaches occur in groups or clusters, aura preceeding headache, visual flashes or partial visual loss before the headache, alcohol or drugs precipitate a headache, chocolate consumption precipitates a headache, recently stopped taking any substance like a medication, drug, alcohol, caffeine or nicotine.Headaches are accompanied by nuasea, vomitting, paresthesia or weakness associated with headache, eyes water or become red with headaches, headaches are accompanied by frequent urination, nasal congestion or discharge accompanying headaches. Psychiatric She reported history of suicidal idea or attempt, change in financial state within the last six months, change in responsibilities at work within the last six months, mild stressed feeling, enjoys interaction with opposite sex some of the time, normal thinking most of the time, normal activities most of the time, life full most of the time, irritable some of the time, iquickly becomes too tired to carry out activities, decisive most of the time, hopeful good part of the time, useful good part of the time, enjoy activities good part of the time. She denied personality changes in last six months, emotional complaints, recent stress, tobacco pipe, tobacco smokeless, tobacco use more than 10 years, personality change before headache. Risk Factors Physical Conditioning She reported less than 30 mins exercise per day Nutrition
  41. 41. She denied pressure or pain in chest, heart murmur, intermittent chest pain, heavy squeezing tight chest pressure, edema, varicose veins, claudication. Gastrointestinal She denied gastrointestinal symptoms, nausea, diarrhea, constipation, change in bowel habits, yellow rash. Genitourinary She denied genitourinary symptoms, dysuria, vaginal discharge. Endocrine She denied gland trouble, diabetesm goutm or thyroid condition, change in thirst or appetite. Hematological Muskuloskeletal She denied excessive bleeding, swollen glands She denied rheumatic symptoms, swelling of extremities. Neurologial She reported frequent headaches, headaches more than twice a month, headache similar to previous headaches, onset of headaches under age of 24. She denied motor disturbances, dyssomnia, headaches usually periorbital at onset, periauricular headaches associated with opening jaw, headaches cause awakening from sleep, headaches more frequent certain days of the week, headaches occur in groups or clusters, aura preceeding headache, visual flashes or partial visual loss before the headache, alcohol or drugs precipitate a headache, chocolate consumption precipitates a headache, recently stopped taking any substance like a medication, drug, alcohol, caffeine or nicotine.Headaches are accompanied by nuasea, vomitting, paresthesia or weakness associated with headache, eyes water or become red with headaches, headaches are accompanied by frequent urination, nasal congestion or discharge accompanying headaches. Psychiatric She reported history of suicidal idea or attempt, change in financial state within the last six months, change in responsibilities at work within the last six months, mild stressed feeling, enjoys interaction with opposite sex some of the time, normal thinking most of the time, normal activities most of the time, life full most of the time, irritable some of the time, iquickly becomes too tired to carry out activities, decisive most of the time, hopeful good part of the time, useful good part of the time, enjoy activities good part of the time. She denied personality changes in last six months, emotional complaints, recent stress, tobacco pipe, tobacco smokeless, tobacco use more than 10 years, personality change before headache. Risk Factors Physical Conditioning She reported less than 30 mins exercise per day Nutrition
  42. 42. Patients collect info that Clinicians miss #ICASM2015 40% of the time the questionnaire provided useful information that would not be typically elicited Essential Questions aren't missed Pilot’s Checklist
  43. 43. Relevance to Pilot Assessment #ICASM2015 Psychological issues Illicit Drugs Alcohol Documentation Evidence strongly suggests that people will be more honest with the CPI than face to face.
  44. 44. Completeness #ICASM2015 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.
  45. 45. Alcohol #ICASM2015 Alcoholic Captain “Wanted to be caught” Wasn’t asked the right questions CPI would have asked
  46. 46. Let Pilots do the work #ICASM2015 The use of Computer Patient Interviewing allows pilots to give a very full history whilst saving the AME time. This will capture sensitive information at least as well as a face to face questions and probably more reliable. Many more direct questions can be asked. Standard Instruments can be administered and scored as a routine (PHQ-9, GAD-7 etc)
  47. 47. Outcomes of using CPI #ICASM2015 More complete questioning. Better documentation which in turn will enhance the ability to compare responses over time. Much better coded data. Standard Instruments scored. Improved assessment and particularly Psychological. We will be seen to be improving our processes.
  48. 48. Change Management in Healthcare #ICASM2015 “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
  49. 49. Thank you for your interest #ICASM2015 Dr Richard Sills rosills1@gmail.com +44 (0) 7940836337 slideshare.net/ICASM2015 (If you would like to add your slides to the collection please email them to me)
  50. 50. https://www.youtube.com/watch?v=uY32p_BqPw0
  51. 51. “Yes, yes, Mrs Jones... ...we'll talk about your chest pain in one minute. Right now I'm just trying to remember my password”
  52. 52. A machine cannot come between me and my Patient! #ICASM2015 All of this is true It need not happen
  53. 53. A case (thanks to Prof Bachman) #ICASM2015 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
  54. 54. 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
  55. 55. A case (thanks to Prof Bachman) #ICASM2015 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....
  56. 56. What can we learn from this? #ICASM2015 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
  57. 57. Embarrassing Topics #ICASM2015 CPI allows patients to more easily disclose information about embarrassing topics eg. computer interviewing for pelvic floor symptoms in both primary care and hospital found ‘Despite the taboo nature of many of the items, the questionnaire was well received by women in both settings’ Radley SC, Jones GL, Tanguy EA, Stevens VG, Nelson C, Mathers NJ. Computer interviewing in urogynaecology: concept, development and psychometric testing of an electronic pelvic floor assessment questionnaire in primary and secondary care. BJOG 2006;113(2):231-238.

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