Enhancing Clinical History Taking Through the Implementation of a Streamlined Electronic Questionnaire System at a Pediatric Headache Clinic: Development and Evaluation Study

Abstract

Abstract BackgroundAccurate 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. ObjectiveThis 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. MethodsAn 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. ResultsImplementation of the BEST-Survey system significantly increased the mean data acquisition rate from 54.6% to 99.3% (P< ConclusionsThe 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.