ABSTRACT
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.
ABSTRACT
BACKGROUND: Laminoplasty is an established treatment for cervical myelopathy. Multiple variations have emerged, many advocating the use of allograft, but controversy persists. OBJECTIVE: To assess medium-term clinical outcomes in patients who underwent laminoplasty with autograft at our institution. METHODS: Thirty-two consecutive patients (19 male, 13 female, average age 66 yr) from our prospective outcome registry that underwent cervical laminoplasty between 2009 and 2013 were reviewed. Computed tomography (CT) scan was performed immediately postoperatively and at 6-mo follow-up. Parameters included patient perception of outcome, Nurick score, Neck Disability Index (NDI), visual analog scale for neck pain, and SF-36. RESULTS: On retrospective analysis, all patients felt improved at 3 mo postoperatively; at 2 yr, this rate was 91%. Improvements were seen in Nurick scores, from 3.16 ± 0.9 preoperatively to 1.94 ± 0.8 at 2 yr; NDI score from 28.7% ± 9% preoperatively to 20.8% ± 9.6% at 2 yr; visual analog scale from 2.8 ± 1.2 preoperatively to 1.7 ± 0.9 at 2 yr; and SF-36 physical component summary from 27.9 ± 10 preoperatively to 37.8 ± 11.9 at 2 yr. All values reached significance at all follow-up points ( P < .05) with the exception of 6-mo NDI values ( P = .062). No C5 palsy, graft complications, or reclosure was observed in any patient during the follow-up period. CONCLUSION: Laminoplasty with autograft is a safe and effective method to treat cervical myelopathy, with good medium-term clinical outcome. No reclosures were observed. Bony fusion was seen in all cases on CT scan. Our study found good outcomes in the performance of open-door laminoplasty without hardware, in the treatment of cervical stenosis.
