To establish differential diagnoses, direct diagnostic testing, and direct treatment during medical interactions, an effective and focused history of present illness (HPI) is required. For a study, researchers sought to compare the HPI of notes written by an automated digital intake tool to those written by doctors in accordance with industry standards.
It was a prospective study in an academic emergency department (ED) at a quaternary institution. The Centers for Medicare & Medicaid Services (CMS) level of complexity index and the 5-point Physician Documentation Quality Instrument (PDQI-9) scale were used to comparing notes. Board-certified emergency medicine doctors blinded to the material’s source reviewed it. Prior to note evaluations, reviewers underwent training and calibration. Clinical significance was assigned to differences greater than one point. McNemar’s (binary), Wilcoxon-rank (Likert), and agreement with Cohen’s Kappa were all included in the analysis.
Both the digital note and the conventional clinical note were used to track a total of 148 ED medical interactions. A comparison of note content between matched charts (a digital-standard note on the same patient) and reviewers’ ratings was used to evaluate the note-taking capability. A reasonable level of agreement between reviewers who scored the same patient record was indicated by the reviewer agreement score of kappa 0.56 (CI 0.49-0.64). The average agreement between a traditional clinical note and a digital note, considering all 18 items from the PDQI-9 and CMS scales, was 54.3% (IQR 44.4-66.7%). The content of the conventional and digital notes had a moderate level of consistency (kappa 0.54, 95% CI 0.49-0.60). All of the criteria, with the exception of conciseness, were within the 1-point clinically significant range for the quality of the digital note. The frequency of CMS severity factors found in digital notes was greater.
Except for the conciseness feature, digitally generated clinical notes and traditional clinical notes demonstrated reasonable agreement and a one-point clinically meaningful difference. Digital notes more accurately recorded the severity of the billing components. It was important to further investigate the usage of automated notes to assess their value in streamlining the reporting of patient visits.