Mazer and colleagues report on a single-site trial of a new patient history-gathering format called the “Chronology of Present Illness” (CPI), in the hope of improving upon the more familiar “History of Present Illness”.1 According to the team’s previous work,2 , 3 structuring the histories in timeline format reduces the omission of critical information and facilitates ease of handoffs. Using data gathered in a cross-sectional pre–post mixed-method survey of residents and attending physicians, the goal of this study was to explore provider-reported experiences using this format.
Substantial benefits are reported, especially those related to the gathering of more complete clinical data and ease of communication within the healthcare team. Challenges noted related to integrating CPI into clinical workflow, as it may increase time spent gathering information up front, and may be difficult to reconcile with existing patient histories (presumably recorded in the prose-heavy HPI format). While both benefits and challenges are contextualized with qualitative data, these findings are limited by the manner in which data were collected and the possible influence of social acquiescence among residents. In this case, participants were asked to report on the experience of using the HPI and CPI at the same time. Given that the participants knew that this study was investigating process improvements attributable to CPI, and that residents may feel obligated to report that the newer procedure was better, it is possible that they may have intentionally deflated their pre scores to allow for observable improvement at post. Indeed, reports from attending physicians—who are logically less likely to feel the need to please faculty mentors—illustrated a ceiling effect where observable improvement was not practically possible. The reported advantages of CPI remain compelling, nevertheless, and certainly warrant the application of more rigorous pragmatic trials4 as a next investigational step.
This report illustrates the need for and application of improved patient history-taking. Methodological limitations notwithstanding, Mazer provides insight into possible quality and workflow improvements if CPI were broadly implemented and institutionalized, as well as a strong rationale to investigate the utility of CPI at other sites and with different methodologies.
References
Mazer LM, Storage T, Bereknyei S, Chi J, Skeff K. A pilot study of the chronology of present illness: restructuring the HPI to improve physician cognition and communication. J Gen Intern Med. doi:10.1007/s11606-016-3928-3
Skeff KM. Reassessing the HPI: the Chronology of Present Illness (CPI). J Gen Intern Med. 2014;29:13–5.
Skeff KM. Restructuring the Patient’s History: Enhancing the Consultant’s Role as a Teacher. Gastroenterology. 2014;147:1208–11.
MacPherson H. Pragmatic clinical trials. Complement Ther Med. 2004;12(2):136–40.
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Knoepke, C.E. Capsule Commentary on Mazer et. al., A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication. J GEN INTERN MED 32, 191 (2017). https://doi.org/10.1007/s11606-016-3937-2
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DOI: https://doi.org/10.1007/s11606-016-3937-2