BMC health services research
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
By Roemer A, Wilhelmi T, Fink D and 8 others.
Abstract
Background
Clinical encounters in outpatient care are constrained by high demand, limited consultation time, and documentation requirements. Computer-assisted history-taking (CAHT) may improve the structured collection of patient information before consultations and disease screening, but evidence is limited. This randomized pilot study evaluated whether pre-visit CAHT combined with a copy-ready summary increased documentation completeness and assessed patient and physician acceptance.
Methods
MAESTRI was a multicenter, parallel-group, randomized pilot study conducted across rheumatology, dermatology, and orthopedics outpatient services. Adults at increased risk of an underlying inflammatory rheumatic disease (IRD) were randomized to pre-visit CAHT or usual care. Specialty-specific questionnaires generated structured narrative summaries covering predefined screening-relevant items. The primary outcome was documentation completeness, assessed by a blinded reviewer as the percentage of these predefined items present in the final clinical documentation. Secondary and exploratory outcomes included patient and physician acceptance, usability ratings, and free-text feedback.