uring the typical preanesthesia evaluation, many factors make it difficult for the anesthesiologist to acquire a complete medical history, to adequately inform and educate the patient and to establish a satisfactory doctor-patient relationship. These limiting factors include time constraints (“production pressure”) and patient anxiety when the interview occurs immediately prior to surgery. Computer-patient preanesthesia interview systems^1-3 can gather a medical history before the encounter, offer patient education and save valuable physician time. A comprehensive, automated medical history focuses the physician’s subsequent encounter with the patient on issues most relevant to the patient’s care. Medical practitioners in all specialties tacitly recognize this fact through the use of paper and pencil medical questionnaires in most doctors’ offices.

Computer-patient interviews can improve medical care in several ways¹ [Table 1].

The Interview System
Using Web-based tools, we have developed a novel, free, universally available, Web-based patient self-assessment system: the Pre-Anesthesia Interview (PAI). The PAI prototype is hosted by NetWellness <www.netwellness.org>, a nonprofit organization delivering health care information from three Ohio medical schools to the consumer via the Web. The NetWellness Web site is secured to protect patient privacy and confidentiality. Security is documented in a privacy policy to which users are directed at the beginning of the interview. The interview does not collect and store patient identifiers and thus complies with U.S. Federal health data regulations (Health Insurance Portability and Accountability Act [HIPAA]) that protect personal health information.

After data collection is complete, a printout is produced that the patient may sign and date. A private interview number (PIN) is generated, which the patient can use to return to the site to retrieve or update results. Only the patient can associate the PIN with his/her interview, again assuring compliance with HIPAA regulations.

An “Interview Builder” allows the domain expert (i.e., the anesthesiologist) to create the interview without knowledge of programming, database structure, HTML or other computer-related topics. The questions cover all relevant areas of the preoperative history in 15 sections. Validated questions from scientific, peer-reviewed studies are used in the instances where such questions exist.

A secure database stores all questions, response texts, instructions and educational material. This architecture facilitates design, maintenance and reporting. Because the database is Web-accessible, content is easily updated, and designers in different centers can collaborate.

The interviewee needs basic Web-browsing skills, an eighth-grade reading level and minimal familiarity with a standard keyboard. The great majority of questions require a simple “Yes” or “No” response (single click). “Don’t Know,” “Don’t Understand” or “Skip” options also are offered. These latter responses give more information to the physician than an omitted response and help the designers reword a question or redesign the PAI as necessary. Positive responses ordinarily lead to follow-up questions that explore problems in more depth. For example answering “Yes” to the question “Have you ever had chest pain?” leads to an inquiry about the cause of the chest pain. A failure to answer is recorded and reported. An optional indicator bar graphically charts the patient’s progress. Patients can skip to different parts of the interview rather than answer sequentially.

At the end of the interview, the patient can review the responses, change them or supply missing or skipped answers. The patient then prints the interview results. The output reproduces the questions in their entirety, one per line, with the patient’s response. The patient is asked to bring the printout to the hospital or other venue (e.g., preanesthesia clinic) and present it to the anesthesiologist. We are currently implementing a secure method for e-mailing interview responses directly to the physician while complying with HIPAA regulations.

Clicking on the “Help” icon next to each question displays patient education material that explains the reasons for asking the question and, where appropriate, the meaning of the question. Original text information is supplemented by hyperlinks to other parts of the NetWellness site and, in the future, also will contain hyperlinks to resources outside NetWellness.

The final set of questions in the PAI is an optional patient feedback survey to assess various aspects of the interview, including clarity, presentation and overall value. The printout has a series of questions for the anesthesiologist. This survey is to be collected at collaborating centers and then mailed or faxed for entry in the database and subsequent analysis.

Evaluation of the impact of the interview on time savings and patient care is under development. Our hypothesis is that the PAI system is easy to use, fits workflow, protects health data privacy, enhances patient education, supports clinical decision-making and is compatible with other computerized information systems. We believe the potential benefits of this system justify its use as well as further study to determine impact, optimal design and implementation.

The PAI is available now in French and English and is free! Please try it! The address is <www.netwellness.org/interview/anesthesia>.

Discussion
Future development will focus on improving usability, (e.g., drug look-up features and highlighting the most important clinical information in the printout), developing cross-platform portability (e.g., personal digital assistants), decision support features (e.g., triage, risk profiling), securely transmitting results to authorized hospitals and providers, integrating data with other clinical information databases and data repositories and enhancing the educational and instructional material. Data integration will be fully standards-compliant, including the Anesthesia Patient Safety Foundation Data Dictionary <www.gasnet.org/societies/apsf/ddtf/index.php> and the Systemized Nomenclature of Medicine“, or SNOMED <www.snomed.org>. Perhaps most importantly, future versions of the interview also will collect postoperative outcome data after hospital discharge. Currently outcome data is extremely difficult to collect and equally difficult to correlate with preoperative data. The PAI will be an enormous help in facilitating this process.

The PAI is universally available, at no cost, via the Internet. We seek collaborators who are willing to translate the information into other languages and work together with us on future development. Most of all, we encourage anesthesiologists to offer the interview to their patients.

References:

1. Bachman JW. The patient-computer interview: A neglected tool that can aid the clinician. Mayo Clin Proc. 2003; 78:67-78.

2. Vitkun SA, Gage JS, Anderson DH. Computerization of the preoperative anesthesia interview. Int J Clin Monitoring and Computing. 1995; 12:71-76.

3. Lutner RE, Roizen MF, Stocking CB. The automated interview versus the personal interview: Do patient responses to preoperative health questions differ? Anesthesiology. 1991; 75:394-400.

Gareth S. Kantor, M.D., is Assistant Professor, Department of Anesthesiology, University Hospitals of Cleveland and Case Western Reserve University, Cleveland, Ohio.

John S. Gage, M.D., is Associate Professor, Department of Anesthesiology, State University of New York at Stony Brook, Stony Brook, New York.