Clinical History Taking Versus the Addition of an Electronic File Consultation in Pediatric Pre-operative Assessments
Comparison of Clinical History Taking Versus the Addition of an Electronic Patient File Consultation in Pediatric Pre-operative Assessments
The investigators are studying the difference between the history taken from parents prior
to their child's anesthesia to information gleaned routinely from a patient information
system called Ofek.
Introduction One of the cornerstones of pre-operative assessment is an accurate clinical
history. In pediatric anesthetic practice, the history is typically obtained from an
accompanying parent. A letter from the patient's primary care physician may accompany the
child for elective cases, but typically contains general information and may omit recent
illnesses. In addition, parents may underplay or deny respiratory problems such as upper or
lower respiratory tract infections, asthma, cough or snoring as the norm for a particular
child and not understand their importance in pre-operative assessment.
The Clalit Health Services HMO is Israel's largest health insurer and has a comprehensive
online patient database for healthcare workers to use for patient care. The Ofek patient
electronic record system allows the physician to view patient community and hospital
records, including special investigations and drug prescription and purchases, updated in
real time. Recently, the system was upgraded to view patient records from all of the four
Israeli HMOs. This has enabled the treating physicians' electronic record access to any
patient that may present.
The investigators see this development as a major advantage. Moreover, in the pediatric
pre-anesthetic assessment setting, the clinical history may be verified by the Ofek system.
Aim To compare the details obtained at pre-anesthetic clinical history given by parents of
children undergoing surgery to those obtained using the Ofek electronic patient record
system. In addition, we would like to inquire into the reasons that discrepancies may exist
between clinical histories and the electronic patient record and the clinical impact of
those differences on clinical decision making.
Methods Two hundred children and parent/s will undergo pre-anesthetic clinical history
taking. Each parent and child will be screened pre-operatively by a senior anesthesiology
resident using the Meir Medical Center Anesthesia pre-operative pediatric assessment form.
Thereafter, the resident will open the electronic patient file using the Ofek system and
additional information, if present will be noted. Parents will be asked, where relevant, for
the reason additional information gleaned via Ofek was omitted during the direct
questioning. If the clinical history and/or Ofek resulted in changes in patient management,
this will be noted as well.
Data to be collected will include the number of discrepancies between clinical history and
information obtained using Ofek and the reasons for those differences will be noted. In
addition, the source of all information whether obtained via clinical history or Ofek will
be noted. If information obtained by either of the abovementioned means results in changes
in clinical management, these will be noted as well. The data collected from parents and
Ofek is done so without any connection to the study.
Statistical analysis Comparisons between nominal variables will be analyzed by Chi-Square
and derivatives of it (McNemar, Kappa). Continuous parameters - by paired tests -parametric
and non-parametric,each as appropriate. Reliability between "Ofek" and clinical history will
be measured by Intra-Class Coefficients and coefficient of variations (CoV). All statistical
procedures, each as needed.
Medical History Taking, Electronic Health Records, Pediatrics, Parents
Meir Medical Center
Meir Medical Center