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.

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.

Results: Of 45 screened patients, 43 were randomized and analyzed. The mean age was 54.2 years (SD 14.3), and 29 participants (67.4%) were female. All intervention-group clinical notes contained the generated summary. Overall median documentation completeness was 100.0% (IQR 100.0-100.0) in the intervention group compared with 46.9% (IQR 10.0-68.8) in the control group (p < 0.001), with consistent differences across rheumatology, dermatology, and orthopedics. CAHT acceptance was high among both patients and physicians, with 41 of 43 patients (95.3%) willing to complete and the six responding physicians (100%) willing to offer digital pre-visit questionnaires before future appointments. Qualitative feedback was predominantly positive, with patients reporting that pre-visit questionnaires could improve consultation preparation, support recall of symptoms, and help physicians focus the visit on relevant issues. Some participants emphasized that digital questionnaires should complement, rather than replace, direct physician interaction.

Conclusions: Pre-visit CAHT combined with a structured, copy-ready summary substantially increased the completeness with which predefined screening-relevant information was transferred into clinical documentation while also suggesting high acceptance among both patients and physicians. These findings support further evaluation in a larger trial assessing workflow impact and clinical impact.

Trial registration: The study was registered at German Clinical Trials Register (DRKS; ID: DRKS00036519). Date of Registration: 2025-03-31.