Measures
We obtained demographic data for all patients approached for our study. Refusal rates were one of the main outcomes of the study. When a patient declined to participate, a reason for refusal was noted if possible. Although literacy level was not assessed directly, illiteracy was noted when the information was volunteered.
Another major outcome was the acceptability rating of using the computer to obtain a medical history. Acceptability was determined using a questionnaire consisting of 12 items. Each item was rated on a 4-point Likert scale with higher scores indicating more acceptability.
Statistical Analysis
We analyzed the data with Microsoft Access (Microsoft Corporation, Redmond, Wash), Microsoft Excel, and the Statistical Package for the Social Sciences, version 7 (SPSS Inc, Chicago, Ill). Continuous variables (eg, age, years of education) were described with means and standard errors of the means (SEM). We analyzed the internal consistency of the acceptability questionnaire using Cronbach a and item-total correlations. The effects of categorical variables (eg, sex, race) on the continuous acceptability rating were analyzed using analysis of variance, and the relations among continuous variables were analyzed with Pearson correlation coefficients (r). Significance for all analyses was set at P <.05.
Results
The sample demographics are presented in the Table. Consistent with the clinic population, the sample was approximately 55% women. African Americans constituted 79%. Approximately a third had not completed high school, another third completed high school, and a little less than a third had continued their education beyond high school. The majority (70%) had been to this clinic previously. Ninety-nine percent spoke English as their primary language. More than half of the participants reported that they had not previously used a personal computer. Thirteen patients (13%) refused to participate. The reasons for refusal varied: 4 patients were unable to read well enough to do the study, 1 refused because of dislike for computers, and 3 felt too sick. The other 5 patients gave no reason for refusal.
The acceptability rating items were highly interrelated. Item-total correlations ranged from 0.11 to 0.58, yielding a Cronbach a of 0.75. This represents adequate internal validity and suggests that a single total score (the acceptability rating) is an adequate summary of the items. We averaged the items to obtain acceptability ratings that ranged from 2.0 to 4.0, with a mean of 3.27 (SEM=0.044). Since the maximum possible score was 4.0, this mean corresponds to very positive ratings. Only 4 participants rated the experience below 2.5. Combined with the 13 who refused to participate, only 17% of the subjects rejected or were only slightly positive about the experience.
We examined the effects of demographics and selected patient experiences on the acceptability rating. Sex and race did not have a significant influence. Age had a statistically significant impact (r=-0.27), with increasing age associated with decreasing acceptability. Education (r=0.02) and previous visits to the clinic had no impact on the acceptability ratings. Patients who had used computers before rated the experience slightly more positively (mean=3.8) than patients who reported no previous use (mean=3.6). However, the 0.2 difference may not represent a clinically meaningful increase in acceptance of completing a computerized medical history.
Conclusions
We feel that the positive reactions of 83% of all patients approached about the study is a very strong statement for supporting further examination of software programs for computerized medical interviewing. We have shown that a representative sample of the Charity Hospital patient population was capable of using a computer for a self-administered medical history, and our subjects thought it a good idea. Further study of this clinical tool should not be halted because of fear of patient resistance or refusal. We encourage our colleagues to consider the use of a computerized self-administered patient history as a timesaving cost-effective adjunct to the traditional oral history.
Acknowledgments
Colonel Gordon Black, MHA, Department of Preventive Medicine and Public Health, LSUMC-NO, provided the vision that all our patients can use a computer and demanded that we prove it. His death in November 1997 prevented him from contributing to the writing of this article.