Anamnese in tijden van big data

Een pleidooi voor een standaard om de anamnese vast te leggen
Ter discussie
Martijn P. Bauer, Marieke M. van Buchem en Simone A. Cammel

Er is veel te zeggen voor systemen om klinische besluitvorming te ondersteunen. Deze computerprogramma’s helpen de arts een diagnose te stellen door verschillende patiëntgegevens te combineren en hierin patronen te herkennen. Het succes van deze systemen is echter beperkt. Hoe komt dat?

Clinical history in times of big data; a plea for a standard for the structured recording of the clinical history

Clinical decision support systems to aid the clinician in making a correct diagnosis will only succeed if data from the clinical history are taken into account. However, currently, very little is known on diagnostic test characteristics of specific symptoms, let alone of a pattern of several symptoms with all their cardinal features. We plead for the nation-wide introduction of a standard for the structured recording of the clinical history. To allow for such structured recording, user interfaces of electronic healthcare records must become far more user-friendly. Furthermore, scribes may be used, or, ideally, a digital scribe, a computer application that records the conversation between healthcare professional and patient and creates an automated summary. So far, to our knowledge, no digital scribe encompassing the entire patient history has been implemented into medical practice. We are currently trying to develop such a digital scribe.

Conflict of interest and financial support: potential conflicts of interest have been reported for this article. ICMJE forms provided by the authors are available online along with the full text of this article.