Work

Clinical records organized and optimized for clinical integration and clinical decision making

Year: 2016

Type: article

Abstract: One of the most basic and cost effective skills a healthcare professional (HCP) can employ is correctly diagnosing (90%) a patient by taking an accurate medical history.1,2 A HCP will diagnosis and develop a treatment plan by requesting the following information from the patient: chief compliant, history of present illness, past medical and surgical history, medication history, family history, social history, and conducting a review of systems. In an ideal situation, every patient would be able to recall all of this information immediately, accurately, systematically, and disclose it upon request. However, such ideal conditions rarely exist in the field of health care, particularly amongst an aging population who are afflicted with greater numbers and complexities of comorbid health conditions. Also, economical pressures have forced many hospital systems and individual providers to refocus on the throughput of patients, which has led to less time spent with HCPs. As a result, patients have more health information and less time to convey it and usually end up disclosing: (a) chief complaint (or multiple complaints), (b) some medical history, (c) some family history and (d) a list of medications. Moreover, as the patient moves through the health care process, he or she has subsequent opportunities to provide additional information which may be critical to the diagnosis/treatment of his/her ailment, but not available to every visited provider (i.e. pharmacist, physical therapist, etc.). As a result, with the current system, the probability exists for the fragmentation of critical clinical information which can be unavailable for clinical decision making. Historically, HCPs have used one of two major clinical reasoning paradigms for providing health care: decision making and problem solving.3-6 However, the successful implementation of these paradigms is contingent on complete and accurate documentation of clinical information and the availability of this information for medical decision making. This ideal is rarely met with the current medical record, as it is often proprietary and provider specific. Thus, HCPs are relegated to redundancy in history taking, which can result in errors, loss of efficiency, and ultimately, worse patient care and outcomes. One way to help improve the system is to leverage technology as a tool to help reduce inefficiency and inaccuracy. A systemized Electronic Health Record (EHR) program utilizing a common data repository with the ability to present different views of the clinical data with reminders of when new information is added, will allow for due diligence by HCPs to review all medical notes relevant to a patient. Thus, allowing for adequate time afforded by a health system and utilized by an HCP with each patient can reduce the likelihood that critical information is missed. However, even with integration of technology into the patient care process, critical information can still be missed by individual HCPs. Options are available to help increase the fidelity of the medical record. It could be suggested that having one clinician return to ask the patient for the same information at various points would allow the information to be collected fully-the more points of contact by one HCP, the more complete the history will be. However, expecting a single HCP (especially a physician, who may not have much time to spend with a patient as compared to other HCPs) to return over and over again to the same question/topic may be impractical. Given that fact, the process of having multiple HCPs ask the same or similar questions at multiple points would improve the odds that information will be remembered/revealed, and this approach would be much more likely to be useful in a typical clinical setting. However, for this process to work, each member of the team must be familiar with the skills, training, and roles of the other team members, and have confidence in their ability to gather and interpret needed information. We propose that interprofessional education and collaboration in history taking will lead to the effective capturing and communication of patient information resulting in the best patient-centered outcomes. Definition interprofessional collaboration Benefits of interprofessional education have been demonstrated in the literature. The Institute of Medicine’s seminal 2003 report entitled “Health Professions Education: A Bridge to Quality” called for health care students and working professionals to collaborate on interdisciplinary teams and engage in quality improvement.7 Regrettably, the United States ranks near the bottom among industrialized nations in every quality parameter measure, thus heightening the growing importance of quality care provided within interprofessional teams.2 Contentious battles among the health care disciplines have inhibited collaboration and teamwork.8 Kruse argues that health care providers: often lack respect for others, fail to recognize the value of a team-based approach and a shared vision, and demonstrate a deficiency in communication skills that are required to set goals and priorities aimed to improve health care efficiency and effectiveness. This health care attitude of working in silos exists because we have allowed and even nurtured competitive training programs rather than growing a rich environment grounded in interprofessionalism, teamwork, and collaboration.8 The focus of care needs to shift from the lens of any particular discipline to the lens of patient outcomes. After all the patient comes to us for resolution of a health problem independent of who actually solves it. Interprofessional collaboration is the foundation needed for health care providers to support patient needs9 and improve patient history taking. We define interprofessional collaboration as two or more health care providers from different disciplines collaborating effectively together in order to improve health outcomes for their patients while working with patients, families, and communities to deliver the highest quality of care.10 Over the past decade, there has been a push toward interprofessional collaboration and teamwork.6 Interprofessional collaboration can bring forth the cooperation, communication, and teamwork necessary to provide a comprehensive health care plan to treat and care for the patient.10 The first step to achieving this goal is obtaining an accurate and complete patient history.

Source: International Journal of Medical Education

DOI: 10.5116/ijme.576a.fff4