Cho Jaeso, Han Ji Yeon, Cho Anna, Yoo Sooyoung, Lee Ho-Young, Kim Hunmin
Department of Pediatrics, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 03080, Republic of Korea, 82 317877297.
Department of Pediatrics, Inha University Hospital, Incheon, Republic of Korea.
JMIR Med Inform. 2024 Nov 8;12:e54415. doi: 10.2196/54415.
Accurate history taking is essential for diagnosis, treatment, and patient care, yet miscommunications and time constraints often lead to incomplete information. Consequently, there has been a pressing need to establish a system whereby the questionnaire is duly completed before the medical appointment, entered into the electronic health record (EHR), and stored in a structured format within a database.
This study aimed to develop and evaluate a streamlined electronic questionnaire system, BEST-Survey (Bundang Hospital Electronic System for Total Care-Survey), integrated with the EHR, to enhance history taking and data management for patients with pediatric headaches.
An electronic questionnaire system was developed at Seoul National University Bundang Hospital, allowing patients to complete previsit questionnaires on a tablet PC. The information is automatically integrated into the EHR and stored in a structured database for further analysis. A retrospective analysis compared clinical information acquired from patients aged <18 years visiting the pediatric neurology outpatient clinic for headaches, before and after implementing the BEST-Survey system. The study included 365 patients before and 452 patients after system implementation. Answer rates and positive rates of key headache characteristics were compared between the 2 groups to evaluate the system's clinical utility.
Implementation of the BEST-Survey system significantly increased the mean data acquisition rate from 54.6% to 99.3% (P<.001). Essential clinical features such as onset, location, duration, severity, nature, and frequency were obtained in over 98.7% (>446/452) of patients after implementation, compared to from 53.7% (196/365) to 85.2% (311/365) before. The electronic system facilitated comprehensive data collection, enabling detailed analysis of headache characteristics in the patient population. Most patients (280/452, 61.9%) reported headache onset less than 1 year prior, with the temporal region being the most common pain location (261/703, 37.1%). Over half (232/452, 51.3%) experienced headaches lasting less than 2 hours, with nausea and vomiting as the most commonly associated symptoms (231/1036, 22.3%).
The BEST-Survey system markedly improved the completeness and accuracy of essential history items for patients with pediatric headaches. The system also streamlined data extraction and analysis for clinical and research purposes. While the electronic questionnaire cannot replace physician-led history taking, it serves as a valuable adjunctive tool to enhance patient care.
准确采集病史对于诊断、治疗及患者护理至关重要，但沟通不畅和时间限制常常导致信息不完整。因此，迫切需要建立一种系统，使问卷能在就诊前妥善完成，录入电子健康记录（EHR），并以结构化格式存储在数据库中。
本研究旨在开发并评估一种简化的电子问卷系统——BEST-Survey（盆唐医院全护理电子系统-问卷），该系统与EHR集成，以改善小儿头痛患者的病史采集和数据管理。
首尔国立大学盆唐医院开发了一种电子问卷系统，允许患者在平板电脑上完成就诊前问卷。信息会自动集成到EHR中，并存储在结构化数据库中以供进一步分析。一项回顾性分析比较了在实施BEST-Survey系统前后，从因头痛前往小儿神经科门诊就诊的18岁以下患者那里获取的临床信息。该研究纳入了系统实施前的365例患者和实施后的452例患者。比较两组关键头痛特征的回答率和阳性率，以评估该系统的临床效用。
实施BEST-Survey系统后，平均数据采集率从54.6%显著提高到99.3%（P<0.001）。实施后，超过98.7%（>446/452）的患者获得了诸如发作、部位、持续时间、严重程度、性质和频率等基本临床特征，而实施前这一比例为53.7%（196/365）至85.2%（311/365）。该电子系统有助于全面收集数据，能够对患者群体的头痛特征进行详细分析。大多数患者（280/452，61.9%）报告头痛发作时间在1年以内，颞部是最常见的疼痛部位（261/703，37.1%）。超过一半（232/452，51.3%）的患者头痛持续时间少于2小时，恶心和呕吐是最常见的伴随症状（231/1036，22.3%）。
BEST-Survey系统显著提高了小儿头痛患者基本病史项目的完整性和准确性。该系统还简化了临床和研究目的的数据提取和分析。虽然电子问卷不能取代医生主导的病史采集，但它是增强患者护理的有价值辅助工具。
