AUSTRALIAN PAEDIATRIC JOURNAL
Aust. paediat. J.
(1975) 11:201-203
Experience with automated history taking in Paediatrics by DAVID C. MAUGER, M.B., F.R.A.C.P.* from The Princess Mary Hospital for Children, Park Road, Auckland.
Mauger, D.C. (1975). Aust. paediat. I., 11, 201-203. Experience with automated history taking in paediatrics. An interactive, self administered, computer-based questionnaire was tested using parents of children referred to a public hospital outpatient clinic. The machine was a minicomputer with very basic peripherals. The sample reflected the race and educational distribution of the hospital population. 60 mothers completed a mean of 102 questions in a mean time of 35 minutes. The computer consistently detected more abnormal symptoms than were recorded in the physicians history; on rechecking these were found to be valid. No important symptoms in the areas programmed were not detected by the computer.
The use of computer acquired histories as ‘physician extenders’ is now a widely recognised concept. The literature has grown since the first publication of Slack e t al. (1966), and most major computer manufacturers offer either complete history taking packages or programming tools to facilitate the creation of such systems (Ball, 1973). Despite the general interest, publications relating to paediatric automated history taking have been limited, the best known work utilising a moderately expensive commercially produced system (Pearlmann et al., 1973). The information content of a paediatric history is of two classes: the narrative account of the present illness, and a checklist series of questions relating to developmental milestones, family health revious illnesses etc. This second type of $9 information is well suited to automated acquisition, and its elicitation by physicians is frequently disliked because of its repetitive content. The purpose of this study was to determine if the stereotyped aspects of a standard paediatric history could be acquired in an acceptable and reliable manner using a small laboratory computer. Received 10 January, 1975
*Paediatrician
Material The participants were all mothers of children attending for the first time a general paediatric outpatient clinic at Auckland Hospital. They were referred by their general practitioners. The racial and educational distribution is shown in Table I. The racial distribution is consistent with a random sample from the hospital population, although the patients were not randomly selected. The educational distribution of the hospital population is not known. TABLE I Statistics RelatinP to the Mothers
Race: European (White) Maori Other Polynesians Education: Highest Level Attained 5th form 6th form
42
15 3 35 19
7th form
1
Tertiary
5
The computer was a PDP-8/e with 8K 16 bit words of memory. Peripherals were a single DECtape magnetic tape unit and a Teletype terminal (Teletype Corporation).
202
AUSTRALIAN PAEDIATRIC JOURNAL
Methods The content of the questionnaire is shown in Table 11. No attempt was made to elicit the history of the presenting symptom. The history of developmental milestones was not included as its elicitation requires multiple branch points and random access to a large body of data, features not available within the hardware and software structure. TABLE I1 Questionnaire Content 1. Identification data 2. Directions and dummy question 3. Antenatal and birth history 4. Feeding history 5 . Immunisation history 6. Development history (1 question only) 7. Social (environmental) history 8. Family health 9. Previous illnesses 10. Review of systems 11. Attitudes to the automated questionnaire.
The programming details have been published elsewhere (Mauger, 1973). A core resident driver program selects question from a magnetic tape file, prints it on the teletype and then selects the next question depending on the reply. When all questions are completed a summary is printed and patient file created on magnetic tape. All questions are multichoice. Two formats are used, either yes/no/don’tknow/don’t understand, or selection of a single answer from a longer list of alternatives. There were 50 primary questions which all parents were required to answer. A ‘yes’ reply to any of these brought up further qualifying or modifying (‘secondary’) questions. A ‘no’ reply caused these secondary questions to be skipped. There were 172 questions in total in the bank. A typical question sequence is shown in Fig. 1. The printed summary was compared with the physician’s history. Where discrepancies existed, the parent was requestioned on the point concerned. Results All parents invited to participate did so, and all completed the questionnaire. The mean time to do so was 35 minutes, range 24-43 minutes. The mean number of questions answered was 102, range 61-120.
In all of the 60 histories, abnormal events or symptoms were detected by the computer which were not recorded in the physician’s history. The mean number was 9 , range 5-60. 26 of the physician’s histories recorded abnormal events or symptoms not detected by the computer. Of the 26, 12 recorded one event, 14 two events.
Discussion Other investigators have found that history taking by computer is well accepted by patients, and is reliable. Our experience in eliciting paediatric information from a New Zealand hospital population has been similar. All parents stated they enjoyed participating, even though the computer was housed in uninviting and noisy surroundings. The questionnaire philosophy was understood by most parents after the second question. Children of school age were also usually able to answer the questions and operate the terminal. Most of the time required to complete the questionnaire was taken up waiting for the teletype to type a question or for the magnetic tape to locate the next record. Future questionnaires will be implemented on a machine with disc storage and a video type of terminal. It is anticipated that major reductions in time will be achieved. The restriction of only one branch point for each set of questions proved t o be of practical importance only when programming of the developmental history was attempted. It was found that programming this part of the history required a system such as that of Swedlow et al. (1972) which allowed for infinite branch points.
Conclusions This study differs from previous reports of automated history taking in three respects.
1. The history content was paediatric. 2. The participants had not previously seen a computer or related machine. 3. The computer was comparatively very small. The results indicate that the questionnaire was well received and that the answers elicited were accurate.
D.C. Ma uger
Experience in Paediatrics
203
This study is concerned primarily with data capture, and only t o limited extent with computer storage. However, a characteristic of paediatric medical records is that they grow in a n orderly fashion as the child grows. Files built up in this way are particularly suited t o processing b y electronic methods b y t h e techniques known as updating. The indications are that t h e computer will prove t o be a very powerful aid in gathering, storing and retrieving paediatric clinical information.
REFERENCES Ball, M.J. (1973). How to Select a Computerised Hospital Information System. Basel : Karger. Mauger, D.C. (1973). Automated Medical History with Paediatric Data Files. Decus Program Library. Digital Equipment Corporation Users Society. Maynard, Mass. Pearlmann, M.H., Hammond, W.E. and Thompson, H.K. (1973). An Automated "Well Baby" Questionnaire. Paediutrics, 51 : 972-979. Slack, W.V., Hicks, G.P., Reed, C.E. and Van Cura, L.J. (1966). A Computer Based Medical History System. N e w England Journal of Medicine. 274 : 194-198. Swedlow, D.B., Barnett, G.O., Grossman, J.H. and Souder, D.E. (1972). A Simple Programming System ('Driver') for the Creation and Execution of an Automated Medical History. Computer and Biochemical Research. 5 : 90-98.
Acknowledgement: This study was made possible by a grant from the Medical Research Council of New Zealand.
Correspondence to: Dr. David C. Mauger, Paediatrician, The Princess Mary Hospital for Children, Park Road, Auckland. 1. New Zealand.
Aust. paediat. J.
(1975) 11:201-203
Experience with automated history taking in Paediatrics by DAVID C. MAUGER, M.B., F.R.A.C.P.* from The Princess Mary Hospital for Children, Park Road, Auckland.
Mauger, D.C. (1975). Aust. paediat. I., 11, 201-203. Experience with automated history taking in paediatrics. An interactive, self administered, computer-based questionnaire was tested using parents of children referred to a public hospital outpatient clinic. The machine was a minicomputer with very basic peripherals. The sample reflected the race and educational distribution of the hospital population. 60 mothers completed a mean of 102 questions in a mean time of 35 minutes. The computer consistently detected more abnormal symptoms than were recorded in the physicians history; on rechecking these were found to be valid. No important symptoms in the areas programmed were not detected by the computer.
The use of computer acquired histories as ‘physician extenders’ is now a widely recognised concept. The literature has grown since the first publication of Slack e t al. (1966), and most major computer manufacturers offer either complete history taking packages or programming tools to facilitate the creation of such systems (Ball, 1973). Despite the general interest, publications relating to paediatric automated history taking have been limited, the best known work utilising a moderately expensive commercially produced system (Pearlmann et al., 1973). The information content of a paediatric history is of two classes: the narrative account of the present illness, and a checklist series of questions relating to developmental milestones, family health revious illnesses etc. This second type of $9 information is well suited to automated acquisition, and its elicitation by physicians is frequently disliked because of its repetitive content. The purpose of this study was to determine if the stereotyped aspects of a standard paediatric history could be acquired in an acceptable and reliable manner using a small laboratory computer. Received 10 January, 1975
*Paediatrician
Material The participants were all mothers of children attending for the first time a general paediatric outpatient clinic at Auckland Hospital. They were referred by their general practitioners. The racial and educational distribution is shown in Table I. The racial distribution is consistent with a random sample from the hospital population, although the patients were not randomly selected. The educational distribution of the hospital population is not known. TABLE I Statistics RelatinP to the Mothers
Race: European (White) Maori Other Polynesians Education: Highest Level Attained 5th form 6th form
42
15 3 35 19
7th form
1
Tertiary
5
The computer was a PDP-8/e with 8K 16 bit words of memory. Peripherals were a single DECtape magnetic tape unit and a Teletype terminal (Teletype Corporation).
202
AUSTRALIAN PAEDIATRIC JOURNAL
Methods The content of the questionnaire is shown in Table 11. No attempt was made to elicit the history of the presenting symptom. The history of developmental milestones was not included as its elicitation requires multiple branch points and random access to a large body of data, features not available within the hardware and software structure. TABLE I1 Questionnaire Content 1. Identification data 2. Directions and dummy question 3. Antenatal and birth history 4. Feeding history 5 . Immunisation history 6. Development history (1 question only) 7. Social (environmental) history 8. Family health 9. Previous illnesses 10. Review of systems 11. Attitudes to the automated questionnaire.
The programming details have been published elsewhere (Mauger, 1973). A core resident driver program selects question from a magnetic tape file, prints it on the teletype and then selects the next question depending on the reply. When all questions are completed a summary is printed and patient file created on magnetic tape. All questions are multichoice. Two formats are used, either yes/no/don’tknow/don’t understand, or selection of a single answer from a longer list of alternatives. There were 50 primary questions which all parents were required to answer. A ‘yes’ reply to any of these brought up further qualifying or modifying (‘secondary’) questions. A ‘no’ reply caused these secondary questions to be skipped. There were 172 questions in total in the bank. A typical question sequence is shown in Fig. 1. The printed summary was compared with the physician’s history. Where discrepancies existed, the parent was requestioned on the point concerned. Results All parents invited to participate did so, and all completed the questionnaire. The mean time to do so was 35 minutes, range 24-43 minutes. The mean number of questions answered was 102, range 61-120.
In all of the 60 histories, abnormal events or symptoms were detected by the computer which were not recorded in the physician’s history. The mean number was 9 , range 5-60. 26 of the physician’s histories recorded abnormal events or symptoms not detected by the computer. Of the 26, 12 recorded one event, 14 two events.
Discussion Other investigators have found that history taking by computer is well accepted by patients, and is reliable. Our experience in eliciting paediatric information from a New Zealand hospital population has been similar. All parents stated they enjoyed participating, even though the computer was housed in uninviting and noisy surroundings. The questionnaire philosophy was understood by most parents after the second question. Children of school age were also usually able to answer the questions and operate the terminal. Most of the time required to complete the questionnaire was taken up waiting for the teletype to type a question or for the magnetic tape to locate the next record. Future questionnaires will be implemented on a machine with disc storage and a video type of terminal. It is anticipated that major reductions in time will be achieved. The restriction of only one branch point for each set of questions proved t o be of practical importance only when programming of the developmental history was attempted. It was found that programming this part of the history required a system such as that of Swedlow et al. (1972) which allowed for infinite branch points.
Conclusions This study differs from previous reports of automated history taking in three respects.
1. The history content was paediatric. 2. The participants had not previously seen a computer or related machine. 3. The computer was comparatively very small. The results indicate that the questionnaire was well received and that the answers elicited were accurate.
D.C. Ma uger
Experience in Paediatrics
203
This study is concerned primarily with data capture, and only t o limited extent with computer storage. However, a characteristic of paediatric medical records is that they grow in a n orderly fashion as the child grows. Files built up in this way are particularly suited t o processing b y electronic methods b y t h e techniques known as updating. The indications are that t h e computer will prove t o be a very powerful aid in gathering, storing and retrieving paediatric clinical information.
REFERENCES Ball, M.J. (1973). How to Select a Computerised Hospital Information System. Basel : Karger. Mauger, D.C. (1973). Automated Medical History with Paediatric Data Files. Decus Program Library. Digital Equipment Corporation Users Society. Maynard, Mass. Pearlmann, M.H., Hammond, W.E. and Thompson, H.K. (1973). An Automated "Well Baby" Questionnaire. Paediutrics, 51 : 972-979. Slack, W.V., Hicks, G.P., Reed, C.E. and Van Cura, L.J. (1966). A Computer Based Medical History System. N e w England Journal of Medicine. 274 : 194-198. Swedlow, D.B., Barnett, G.O., Grossman, J.H. and Souder, D.E. (1972). A Simple Programming System ('Driver') for the Creation and Execution of an Automated Medical History. Computer and Biochemical Research. 5 : 90-98.
Acknowledgement: This study was made possible by a grant from the Medical Research Council of New Zealand.
Correspondence to: Dr. David C. Mauger, Paediatrician, The Princess Mary Hospital for Children, Park Road, Auckland. 1. New Zealand.
