JMIR Publications

ABSTRACT

Background:

Patients’ perspectives and social context are critical for optimal chronic disease management and prevention of hospital readmissions. However, patients’ perspectives and their social context are neither routinely assessed using the traditional History and Physical (H&P) nor commonly documented in the electronic health record (EHR). The H&P 360 is a revised H&P template that integrates routine assessment of patient perspectives and goals, mental health, and an expanded social history (behavioral health, social support, living environment and resources, function). While the H&P 360 has shown promise in increasing psychosocial documentation in focused teaching contexts, uptake and impact in routine clinical settings is unknown.

Objective:

Assess the feasibility, acceptability, and impact on care planning of implementing an inpatient H&P 360 template in the EHR for use by fourth-year medical students.

Methods:

Fourth-year medical students on internal medicine sub-internship (subI) services (general medicine, cardiology, intensive care) were given a brief training on the H&P 360 and access to EHR-based H&P 360 templates. Non-ICU students were asked to use the templates at least once per call cycle; use by ICU students was elective. EHR query identified all H&P 360 and traditional H&P admission notes authored by non-ICU students at University of Chicago Medicine (UCM). Of these notes, all H&P 360 and a sample of traditional H&P notes were reviewed by two researchers for presence of H&P 360 domains and impact on patient care. A post-course survey queried all students for perspectives on the H&P 360.

Results:

Of the 13 subIs on general medicine and cardiology at UCM, 46% used the H&P 360 templates at least once which accounted for 14-92% of their authored admission notes (median 56%). Content analysis was performed with 45 H&P 360 notes and 54 traditional H&P notes. Psychosocial documentation across all H&P 360 domains (patient perspectives and goals, mental health, expanded social history elements) was more common in H&P 360 vs. traditional notes. Related to impact on patient care, H&P 360 notes more commonly identified needs (20% H&P 360; 9% H&P) and described interdisciplinary coordination (78% H&P 360; 41% H&P). Of the 11 subIs completing surveys, the vast majority (89%) felt the H&P 360 helped them understand patient goals and improved the patient-provider relationship. Most students (78%) felt the H&P 360 took an appropriate amount of time.

Conclusions:

Fourth year students who applied the H&P 360 using templated notes in the EHR found it feasible and helpful. These students wrote notes reflecting enhanced assessment of goals and perspectives for patient-engaged care and contextual factors important to prevention of re-hospitalization. Reasons some students did not use the templated H&P 360 should be examined in future studies. Uptake may be enhanced through earlier and repeated exposure and greater engagement by residents and attendings.