Implementation of a Biopsychosocial History and Physical Exam Template in the Electronic Health Record: Mixed Methods Study.

BACKGROUND: Patients' perspectives and social contexts are critical for prevention of hospital readmissions; however, neither is routinely assessed using the traditional history and physical (H&P) examination 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). Although the H&P 360 has shown promise in increasing psychosocial documentation in focused teaching contexts, its uptake and impact in routine clinical settings are unknown. OBJECTIVE: The aim of this study was to 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: A mixed methods study design was used. Fourth-year medical students on internal medicine subinternship (subI) services were given a brief training on the H&P 360 and access to EHR-based H&P 360 templates. Students not working in the intensive care unit (ICU) were asked to use the templates at least once per call cycle, whereas use by ICU students was elective. An EHR query was used to identify all H&P 360 and traditional H&P admission notes authored by non-ICU students at University of Chicago (UC) Medicine. Of these notes, all H&P 360 notes and a sample of traditional H&P notes were reviewed by two researchers for the presence of H&P 360 domains and impact on patient care. A postcourse survey was administered to query all students for their perspectives on the H&P 360. RESULTS: Of the 13 non-ICU subIs at UC Medicine, 6 (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 compared with 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 (n=10, 91%) felt the H&P 360 helped them understand patient goals and improved the patient-provider relationship. Most students (n=8, 73%) felt the H&P 360 took an appropriate amount of time. CONCLUSIONS: 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 preventing rehospitalization. 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. Larger-scale implementation studies can help further elucidate the complexities of implementing nonbiomedical information within EHRs.

A 7-Domain Framework That Can Bridge Clinical Care, Health Systems Science, and Health Equity: Lessons From the H&P 360.

The H&P 360 is a reconceptualized history and physical (H&P), which clinical medical students have reported reveals clinically relevant information not elicited by the traditional H&P, informs care planning, promotes interprofessional team care, and enhances patient rapport. In addition to the traditional checklist focused on patients' medical conditions, the H&P 360 includes prompts for gathering limited but critical information in 6 other domains directly relevant to patients' overall health-patient values, goals, and priorities; mental health; behavioral health; social support; living environment and resources; and function. Clinicians are thus reminded to elicit relevant information from each domain appropriate to the context of each clinical encounter. As health systems explore ways to identify and address social drivers of health, medical schools are rapidly expanding curricula beyond biomedical conditions, as reflected in the multifaceted health systems science curriculum. Many of today's medical students struggle to find connections among the core tasks of mastering biomedical clinical medicine, their evolving professional identity and career trajectory, and addressing systemic and societal barriers to population health. The authors argue that the 7-domain framework can serve as a conceptual bridge that links the care of individual patients with topics in the health systems science curriculum to promote health equity. The authors provide illustrative examples of the 7 domains as an organizing lens that can promote curiosity and understanding of seemingly disparate topics, such as interpersonal violence, social drivers of health, and structural racism, as well as help students expand and define their professional identities as physicians beyond diagnosis and treatment of biomedical conditions. The authors invite discussion and experimentation around the use of the 7-domain framework in teaching, assessment, and curriculum development and point to resources for clinical educators for teaching and measuring the effects of the H&P 360 on learners, preceptors, and patients.

A Qualitative Study of Preclinical Medical Students Randomized to Patient-Partnered vs Traditional Clinical Experiences.

Purpose: Longitudinal patient-partnered experiences may promote medical student empathy, but evaluation of such programs is limited. The aim of this study was to compare areas of learning among first-year medical students randomized to a patient-centered track (PCT) or traditional track (TT) longitudinal clinical experience. Methods: PCT students (n=24) were paired with 2 patients and a physician to participate in their patients' care across multiple settings. TT students (n=56) were paired with a physician preceptor and participated in caring for a variety of patients in a single setting. This qualitative study used a phenomenological approach to template analysis, examining and comparing student reflective essays for areas of learning. Results: Three domains of learning emerged: 1) Focus of learning (biomedical, patient-centered); 2) Roles and relationships (clinical skills, relationship-building, teaching from preceptor and patients); and 3) Context of care (health systems science, interprofessional care). PCT students described patient-centered learning, relationship-building, and patients' role as teachers. In contrast, TT students emphasized biomedical learning, clinical skills development, and teaching from physician preceptors. Conclusions: Longitudinal patient-partnered clinical experiences provide rich opportunities for preclinical students to cultivate empathy and develop patient-centered values.

Primary care physician involvement during hospitalisation: a qualitative analysis of perspectives from frequently hospitalised patients.

OBJECTIVE: To explore frequently hospitalised patients' experiences and preferences related to primary care physician (PCP) involvement during hospitalisation across two care models. DESIGN: Qualitative study embedded within a randomised controlled trial. Semistructured interviews were conducted with patients. Transcripts were analysed using qualitative template analysis. SETTING: In the Comprehensive Care Programme (CCP) Study, in Illinois, USA, Medicare patients at increased risk of hospitalisation are randomly assigned to: (1) care by a CCP physician who serves as a PCP across both inpatient and outpatient settings or (2) care by a PCP as outpatient and by hospitalists as inpatients (standard care). PARTICIPANTS: Twelve standard care and 12 CCP patients were interviewed. RESULTS: Themes included: (1) Positive attitude towards PCP; (2) Longitudinal continuity with PCP valued; (3) Patient preference for PCP involvement in hospital care; (4) Potential for in-depth involvement of PCP during hospitalisation often unrealised (involvement rare in standard care; in CCP, frequent interaction with PCP fostered patient involvement in decision making); and (5) PCP collaboration with hospital-based providers frequently absent (no interaction for standard care patients; CCP patients emphasising PCP's role in interdisciplinary coordination). CONCLUSION: Frequently hospitalised patients value PCP involvement in the hospital setting. CCP patients highlighted how an established relationship with their PCP improved interdisciplinary coordination and engagement with decision making. Inpatient-outpatient relational continuity may be an important component of programmes for frequently hospitalised patients. Opportunities for enhancing PCP involvement during hospitalisation should be considered.

Preventing Diabetes in Primary Care: Providers' Perspectives About Diagnosing and Treating Prediabetes.

IN BRIEF Offering patient-centered care to prevent diabetes will require collaborative decision-making between patients with prediabetes and their health care providers. From the perspective of primary care providers, prediabetes detection should be targeted to patients who are most likely to benefit from diagnosis and treatment. Improving access to lifestyle intervention programs and educating providers about evidence-based treatments for prediabetes and how to effectively discuss treatment options with patients may improve both providers' and patients' engagement in diabetes prevention.

Patient Perceptions About Prediabetes and Preferences for Diabetes Prevention.

PURPOSE: The purpose of this study was to explore how adults with prediabetes perceive their risk of developing diabetes and examine their preferences for evidence-based treatment options to prevent diabetes. METHODS: A qualitative study was conducted in 2 large Midwest primary care practices, involving in-depth semistructured interviews with 35 adult patients with prediabetes. RESULTS: This ethnically diverse (77% nonwhite) sample of middle-aged primary care patients exhibited multiple diabetes risk factors. Knowledge gaps about prediabetes and its medical management were pervasive. Most patients overestimated the risk of developing diabetes and were not familiar with evidence-based treatment options for prediabetes. They suggested that receiving brief, yet specific information about these topics during the study interview motivated them to act. The majority of participants considered both intensive lifestyle intervention and metformin acceptable treatment options. Many preferred initial treatment with intensive lifestyle intervention but would take metformin if their efforts at lifestyle change failed and their primary care physician recommended it. Some participants expressed wanting to combine both treatments. CONCLUSIONS: This qualitative study highlights potential opportunities to promote patient-centered dialogue about prediabetes in primary care settings. Providing patients specific information about the risk of developing diabetes and evidence-based treatment options to prevent or delay its onset may encourage action. Physicians' prediabetes counseling efforts should be informed by the finding that most patients consider both intensive lifestyle intervention and metformin acceptable treatment options.

Perspectives on prevention of type 2 diabetes after gestational diabetes: a qualitative study of Hispanic, African-American and White women.

Women with gestational diabetes (GDM) have a fivefold higher risk of developing type 2 diabetes (T2DM). Furthermore, Hispanic and African-American women are disproportionately affected by GDM, but their views on prevention of T2DM after gestational diabetes are largely unknown. We conducted semi-structured interviews with 23 women (8 Hispanic, 8 African-American, 7 non-Hispanic White) from two academic clinics in Chicago, IL. Interview questions elicited perspectives on prevention of T2DM; the interview protocol was developed based on the Health Belief Model. Two investigators applied template analysis to identify emergent themes. Women conceptualized risk for T2DM based on family history, health behaviors, and personal history of GDM. A subgroup of women expressed uncertainty about how GDM influences risk for T2DM. Women who described a strong link between GDM and T2DM often viewed the diagnosis as a cue to action for behavior change. T2DM was widely viewed as a severe condition, and desire to avoid T2DM was an important motivator for behavior change. Children represented both a key motivator and critical barrier to behavior change. Women viewed preventive care as important to alert them to potential health concerns. Identified themes were congruent across racial/ethnic groups. Diagnosis with GDM presents a potent opportunity for engaging women in behavior change. To fully harness the potential influence of this diagnosis, healthcare providers should more clearly link the diagnosis of GDM with risk for future T2DM, leverage women's focus on their children to motivate behavior change, and provide support with behavior change during healthcare visits in the postpartum period and beyond.

Health-care access and weight change among young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

OBJECTIVE: Health-care access is associated with improved control of multiple chronic diseases, but the association between health-care access and weight change is unclear. The present study aims to test the association between health-care access and weight change. DESIGN: The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a multicentre population-based prospective study. Weight change was calculated at 3 and 13 years after CARDIA year 7 (1992-1993). Health-care access was defined as no barriers or one or more barriers to access (health insurance gap, no usual source of care, not seeking care due to expense). Intermediary variables evaluated included history of dieting and use of diet pills, meal replacements or weight-control programmes. SETTING: Four cities in the USA. SUBJECTS: Participants were aged 18-30 years at baseline (1985-1986). Analyses include 3922 black and white men and women with relevant data from CARDIA years 7, 10 and 20 (1992-1993, 1995-1996 and 2005-2006, respectively). RESULTS: Mean weight change was +2.22 kg (+4.9 lb) by 3 years and +8.48 kg (+18.7 lb) by 13 years, with no differences by health-care access. Being on a weight-reducing diet was not consistently associated with health-care access across examinations. Use of diet pills, meal replacements or organized weight-control programmes was low, and did not vary by health-care access. CONCLUSIONS: Weight gain was high irrespective of health-care access. Public health and clinical approaches are needed to address weight gain.

South Asian American perspectives on overweight, obesity, and the relationship between weight and health.

INTRODUCTION: Compared with other racial groups, South Asian adults develop type 2 diabetes and cardiovascular disease at a lower body mass index (BMI). Perceptions of weight and the effect of weight on health can influence weight-loss attempts but are not well described in this population. The objective of this study was to examine perceptions of weight appropriateness and the effect of weight on health among South Asian Americans. METHODS: We recruited 75 South Asian American adults from a single metropolitan area in the Midwestern United States. During individual, face-to-face interviews, we asked participants what they think about their weight and how weight affects their health. We measured their weight and height and calculated BMI. Each interview was audiotaped, transcribed verbatim, and translated into English. We conducted analyses using NVivo software. A second investigator coded 20% of interviews to verify coding consensus. RESULTS: Sixty-seven percent of participants were overweight or obese; 40% of overweight participants and 12% of obese participants perceived themselves to be normal weight or underweight. Forty-eight percent of overweight and 82% of obese participants believed their weight affected their health. Participants commonly cited physical problems as being associated with their weight, but few connected their weight with risk for chronic diseases. CONCLUSION: South Asian Americans may underestimate their weight status and the effect of their weight on their risk for chronic diseases. Interventions to promote weight loss among South Asian Americans should focus on modifying perceptions of normal weight and personalizing the relationship between overweight and chronic diseases.

Electronic tools to assist with identification and counseling for overweight patients: a randomized controlled trial.

BACKGROUND: Physicians often do not recognize when their patients are overweight and infrequently counsel them about weight loss. OBJECTIVE: To evaluate a set of electronic health record (EHR)-embedded tools to assist with identification and counseling of overweight patients. DESIGN: Randomized controlled trial. PARTICIPANTS: Physicians at an academic general internal medicine clinic were randomized to activation of the EHR tools (n = 15) or to usual care (n = 15). Patients of these physicians were included in analyses if they had a body mass index (BMI) between 27 and 29.9 kg/m(2). INTERVENTION: The EHR tool set included: a physician point-of-care alert for overweight (BMI 27-29. 9 kg/m(2)); a counseling template to help physicians counsel patients on action plans; and an order set to facilitate entry of overweight as a diagnosis and to order relevant patient handouts. MAIN MEASURES: Physician documentation of overweight as a problem; documentation of weight-specific counseling; physician perceptions of the EHR tools; patient self-reported progress toward their goals and perspectives about counseling received. KEY RESULTS: Patients of physicians receiving the intervention were more likely than those of usual care physicians to receive a diagnosis of overweight (22% vs. 7%; p = 0.02) and weight-specific counseling (27% vs. 15%; p = 0.02). Most patients receiving counseling in the intervention group reported increased motivation to lose weight (90%) and taking steps toward their goal (93%). Most intervention physicians agreed that the tool alerted them to patients they did not realize were overweight (91%) and improved the effectiveness of their counseling (82%); more than half (55%) reported counseling overweight patients more frequently (55%). However, most physicians used the tool infrequently because of time barriers. CONCLUSIONS: EHR-based alerts and management tools increased documentation of overweight and counseling frequency; the majority of patients for whom the tools were used reported short-term behavior change.

Physician counseling of young adults with rapid weight gain: a retrospective cohort study.

BACKGROUND: The incidence of weight gain is highest during young adulthood. Our study aims to describe weight gain patterns among young adults and to evaluate physician recognition of and counseling for rapid weight gain. METHODS: This retrospective cohort study included patients ages 18-35 at an academic internal medicine clinic between 2004-2008. We conducted chart reviews to determine weight change over time, whether weight gain greater than 3 lbs/year was documented, whether counseling was provided, and whether patients became overweight. We categorized weight gain documentation by location on the problem list, encounter diagnosis, or note text. We categorized counseling as weight-specific or general diet and exercise counseling. We used Chi-square tests to evaluate the relationship between weight change over time and the following variables: gender, diagnosis of weight gain, and counseling for weight gain. Fisher's Exact test was used to test for an association between diagnosis and counseling category. RESULTS: The study included 365 patients. Weight gain was greater than 3 lbs/year for 24% (90/365) of patients, of whom 56 (15%) gained 3-5.9 lbs/year, and 34 (9%) gained more than 6 lbs/year. Among patients gaining more than 3 lbs/year, physicians documented weight gain as a problem in only 10% (9/90). Of the 9 patients for whom weight gain was documented, physicians provided weight-specific counseling in three, and general diet and exercise counseling in four. Of the 81 individuals with no documented diagnosis of weight gain, 63% had no documented counseling, but 34% received general diet and exercise counseling. Among patients with over 180 days of follow-up, 8% (10/126) became overweight. CONCLUSIONS: Physicians infrequently recognize or counsel for weight gain among young adult patients. Improving identification of patients with rapid weight gain can provide an opportunity for tailored weight-related counseling.

The neighborhood health exchange: developing a community partnership in residency.

BACKGROUND: The current system of residency training focuses on the hospital setting, and resident exposure to the surrounding community is often limited. However, community interaction can play an important role in ambulatory training and in learning systems-based practice, a residency core competency. The goal of the Neighborhood Health Exchange was to develop a community partnership to provide internal medicine residents with an opportunity to interface with community members through a mutually beneficial educational experience. METHODS: Internal medicine residents received training during their ambulatory block and participated in a voluntary field practicum designed to engage community members in discussions about their health. Community members participated in education sessions led by resident volunteers. RESULTS: Resident volunteers completed a survey on their experiences. All residents stated that the opportunity to lead an exchange was very useful to their overall residency training. Eight exchanges were held with a total of 61 community participants, who completed a 3-question survey following the session. This survey asked about the level of material, the helpfulness of the exchanges, and opportunities for improvement. We received 46 completed surveys from community members: 91% stated that the material was presented "at the right level" and 93% stated that the presentations were somewhat or very helpful. Eighty percent gave positive and encouraging comments about the exchange. CONCLUSION: Effective community partnerships involve assessing needs of the stakeholders, anticipating leadership turnover, and adapting the Neighborhood Health Exchange model to different groups. Community outreach can also enhance internal medicine ambulatory training experience, provide residents with patient counseling opportunities, and offer a novel method to enhance resident understanding of systems-based practice, especially within the larger community in which their patients live.

Internal medicine residents' comfort with and frequency of providing dietary counseling to diabetic patients.

BACKGROUND: Resident physicians' preparedness to provide dietary counseling for the rising number of diabetic patients is unclear. OBJECTIVE: To assess the comfort with, frequency of, and perceived effectiveness of diabetic dietary counseling by internal medicine (IM) residents. DESIGN: Cross-sectional survey. PARTICIPANTS: One hundred eleven IM residents at a single academic institution. RESULTS: Survey response rate was 94%. Fewer residents (56%) were comfortable with diabetic dietary counseling compared with counseling on symptoms of hypo/hyperglycemia (90%, p < 0.001). Residents less frequently provided diabetic dietary counseling (63%), compared with counseling for medication adherence (87%, p < 0.001). The 28% of residents reporting prior education with chronic disease self-management were more comfortable with diabetic dietary counseling (OR 3.2, 95% CI 1.4-7.3, p = 0.006), and reported counseling more frequently, although this difference was not statistically significant (OR 1.8, 95% CI 0.86-3.8, p = 0.12). More frequent counseling was reported by those residents who were more comfortable (OR 1.5, 95% CI 1.0-2.2, p = 0.03) or felt more effective (OR 3.6, 95% CI 2.1-6.1, p < 0.001) with their diabetic dietary counseling. CONCLUSION: Overall, IM residents reported low levels of comfort with and frequency of diabetic dietary counseling. However, residents who were more comfortable or who felt more effective with their dietary counseling counseled more frequently.

Education, literacy, and health: Mediating effects on hypertension knowledge and control.

OBJECTIVE: To determine whether literacy mediates the association between education, hypertension knowledge and control. METHODS: In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control. RESULTS: In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1-8: beta=-0.30, 95% CI=-1.44-0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10-2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54-4.70). CONCLUSION: Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure. PRACTICE IMPLICATIONS: Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.

Domestic violence compared to other health risks: a survey of physicians' beliefs and behaviors.

BACKGROUND: Physicians routinely confront patient risk behaviors once considered private, including tobacco use, alcohol abuse, and HIV/STD-risk behavior. We compared physicians' behaviors and beliefs on screening and intervention for domestic violence with each other risk. METHODS: Survey of nationwide, random sample of 610 primary care physicians from the American Medical Association Physician Masterfile. RESULTS: Fewer primary care physicians screened for domestic violence than for other risks (p <0.001); once domestic violence was identified, however, physicians intervened with equal or greater frequency than for other risks. Fewer believed that they knew how to screen or intervene for domestic violence compared with other risks, and significantly fewer believed that domestic violence interventions were successful compared with interventions for tobacco and HIV/STD risks (Bonferroni adjusted p<0.001). CONCLUSIONS: Lower domestic violence screening rates may reflect physicians' beliefs that they do not know how to screen or intervene, and that interventions are less successful for domestic violence than for other risks. We may improve screening rates by educating physicians that a simplified role, as for other risks, can be effective for domestic violence.