Medical History Taking Using Electronic Medical Records: A Systematic Review
Luis Lino, Henrique Martins
Abstract
ABSTRACT Background: The relationship between digital tools and medical history taking (classically referred to as anamnesis) in clinical settings is problematic. We explored the medical history taking context, how data is managed by physicians and patients and which tools are used, particularly electronic health record, to gather, organize and record patient’s medical history and related health data. Materials and methods: Systematic review of the literature following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines, using published studies in English-language available from PubMed and Cochrane databases, using a combination of Medical Subject Headings and keywords. Our search yielded 162 citations of which 18 corresponded to our criteria and were included, regardless of study design, sample size or measurement type as a variety of perspectives and methodologies was deemed useful for an exploratory review and under a socio-technical research epistemology. The small number of publications related to the topic conditioned our analysis. Discussion: This review shows the paucity of relevant studies in the area of interest. Even thought it was possible to evaluate context changes in history taking that relate to EHR implementation and usage. Also, multiple challenges, benefits, risks and workflow adaptations have impacts on medical history taking. A potentially useful workflow adaptation is the access to the EHR previously or during the patient encounter with him or her. Conclusion: With the ever-increasing adoption of EHRs and its varying influence in clinical practice, physician’s adaptability was strained. Multiple workflow challenges and necessary changes regarding EHR use have been identified. Improving anamnesis practice is possible through better documentation, EHR templates and tools. Yet a new aspect of anamnesis – Digital anamnesis – benefits from better conceptualization and integration with classic anamnesis still taught in traditional medical schools. This study points to implications for medical schools and medical education in general. Highlights: