Rethinking the Social History in the Oct. 2 issue of the New England Journal of Medicine

October 12, 2014

Several months ago, I accompanied an older friend to her first visit with a “diabetologist.” We waited along with at least a dozen other new patients. Each patient was given the typical clipboard with pages of questions to be answered. Maybe it was the soothing sound of the bubbling fish tank or the small intimate nature of the waiting room, but the patients started to chat with each other and ask why these questions were not available to be answered from their home computers, tablets or phones. One man in his 50s exclaimed “This is the third time this month I’ve answered the same sort of questions! First my regular doctor, then my cardiologist and now here! I thought we had electronic health records!” Other patients chimed in with similar comments, and one deaf woman in her 40s (who read lips, but whose speech could not be understood by the medical assistant) gesticulated with her smart phone and clipboard, clearly agreeing that she would prefer to answer the questions electronically.

Behforouz, Drain and Rhatigan’s recent Rethinking the Social History in the Oct. 2 issue of the New England Journal of Medicine ( http://www.nejm.org/doi/full/10.1056/NEJMp1404846 ) aims to motivate physicians to expand their social history interview to include “new” items such as diet and exercise, financial, English literacy, health literacy, self-perceived health, barriers to medication adherence and more. Missing from the list are other crucial topics such as sleep habits, self-medication behaviors (prescribed and over-the-counter medications and supplements, and alcohol – including when each agent is taken), allergies/food intolerances and symptoms, including a pain scale. One of my colleagues likes to cite her mantra “It’s the workflow, stupid!” every time one of us comes up with another great idea to improve patient outcomes. How can a complete history be obtained in the workflow of the average practice that has small, crowded waiting rooms, full exam rooms and 14 minute visits and who is going to pay for the additional time and effort to conduct the expanded social history interview?

Medical sociologists, public health nurses and registered dietitians (RDs) as well as nurse practitioners (NPs) have long obtained social histories in their scope of practice and pharmacists are now querying patients about their social history as they conduct Medication Therapy Management (MTM). While adding RDs, NPs and pharmacists to group primary care practices improves patient outcomes, using these health professionals to conduct patient social histories prior to the primary care visit is not using skills at the top of their licenses – and does not solve the associated workflow issues and costs.

Why not enable patients to report their social histories electronically? Intuitive user interfaces are being designed to enable medical assistants to conduct both social and medication use histories as they sit beside the patient. (We say beside because the interviewer should communicate with the patient, not the device in order to avoid the problem of the “third person” in the room dominating the interviewer’s attention). Medical assistants can conduct these interviews with patients in the office or home – or speak with patients by phone or video. Medical assistants are cost efficient – but they need private office space and practices need enough of them to maintain adequate patient flow.

Many patients (or their family members or other caregivers) could complete these histories at home before their office visit – using secure HIPPA compliant servers. Interfaces for patients are being designed with universal usability, i.e. consideration of lower health literacy (simple language, use of illustrative icons and animations) and various psychomotor skills (large targets and scroll bars that can be used with a finger or stylus, voice activated, etc.).  Behforouz, Drain and Rhatigan conclude: “To be able to treat the patient, a physician must ask the right questions and know how to act on the answers”.

The workflow problem of collecting social histories can be solved. Acting on the answers includes considering the patient’s health behaviors as an essential data channel and integrating those data into all of our electronic systems, algorithms, and support tools.  We need to make sure our process for asking the right questions is not only patient friendly and efficient, but is done in a way that maximizes the efficiency of the health care team ( it’s “the workflow, stupid”), and is truly incorporated into our actions and decisions on behalf of the patient.

Patricia J Neafsey, PhD (pharmacology): Co-founder and Principal Scientist, ActualMeds Corporation.  Professor Emeritus, University of Connecticut School of Nursing. @PharmacoQueen

Joseph Gruber, RPh, CGP, FASCP: Chief Clinical Officer, ActualMeds Corporation.  Past President, American Society of Consultant Pharmacists. @jgactualmeds

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