Effect of pre-visit computer-assisted history-taking with a structured copy-ready summary on documentation completeness in screening for inflammatory rheumatic diseases: a randomized pilot study.
Anna Roemer, Tim Wilhelmi, Daniel Fink et al.
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In 30 seconds
This multicenter, parallel-group randomized pilot study assessed pre-visit computer-assisted history-taking (CAHT) with a structured, copy-ready summary in adults at increased risk of inflammatory rheumatic disease attending rheumatology, dermatology, or orthopedics outpatient services. Among 43 randomized participants, median completeness of predefined screening-relevant items in clinical documentation was 100.0% (IQR 100.0-100.0) with CAHT versus 46.9% (IQR 10.0-68.8) with usual care (p < 0.001). Patient and physician acceptance was also high. The authors conclude that larger studies are needed to assess workflow and clinical impact.
Key findings
- Median documentation completeness was 100.0% (IQR 100.0-100.0) with CAHT versus 46.9% (IQR 10.0-68.8) with usual care (p < 0.001).
- All intervention-group clinical notes included the generated summary, with documentation differences consistent across the three outpatient specialties.
- 41 of 43 patients (95.3%) were willing to complete future digital pre-visit questionnaires; all six responding physicians (100%) were willing to offer them.
Why it matters
Structured pre-visit information may help transfer screening-relevant history into clinical records, addressing a documentation challenge in time-constrained outpatient care. The findings also suggest that patients and physicians may accept this approach. However, improved documentation completeness is not evidence that screening accuracy, workflow, or patient outcomes improve; those effects require further evaluation.
What to keep in mind
This was a randomized pilot study with 43 participants, and only six physicians responded to the acceptance assessment. Workflow and clinical impact were not evaluated.