1. Introduction

Long before modern hospitals started, folk medicine relayed on supernatural causes and human interaction [1] for diagnosis. Since an important pilar of medicine was the knowledge of people’s complaints and their past relevant experiences. In health, history taking of complaints as well as past events gave rise to anamnesis in ancient Greek medicine – a clinical process basilar to medicine. It has been used in medical care for centuries as a means to understand patients and their underlying conditions. It is estimated that only from the patient interview, a doctor with adequate communication skills could make a correct diagnosis in 76% of the times [2].

From such process, critical reasoning and causation with information gathered by a physician through asking specific questions, either to the patient or to other people who know the person, with the aim of obtaining useful evidence allows the formulation of a diagnosis or diagnosis hypotheses upon which medical care provision can be organized. Interview skills contribute significantly to problem detection, diagnostic accuracy, patient and physician satisfaction. Communication skills in general help patient adjustment to stress and illness, patient recall of information, adherence to therapy and health outcomes in general [3]. It is to be expected that even into the next millennia physicians (either humans or artificial intelligence) shall rely upon this method to practice medicine.

A dramatic increase in chronic care versus acute care management is observable. Human mean life expectancy rises, and populations get progressively older, chronic diseases become more prevalent. A systematic review estimated the total number of people with dementia to nearly double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050 [4]. Amongst these, dementia and age-associated progressively memory loss have become especially debilitating conditions limiting the capacity for interviewing patients.

With the appearance of Electronic Health Records (EHR), physicians gained a new tool in care giving. Being able to gather more information through means parallel with classic anamnesis, complementing and facilitating patient care.

Electronic Health Records (EHR) comprise health information of a patient showing clinical data collected from all healthcare professionals involved in the care process, including doctors, nurses, therapists and other specialists [3]. These systems also receive increasing amounts of automatically generated data, from laboratory to imaging data. Derived from a wide range of interconnected medical devices.

The widespread adoption of EHR has changed physician’s workspace and brought new challenges in care giving. In addition to playing a critical role in facilitating and delivering patient care, the record serves as a medicolegal instrument and the data stored within it is used for other administrative activities, including coding and billing [5].

Several benefits have been associated with EHR use in clinical practice. Increased adherence to guidelines in preventive care, decreased paperwork for providers, improvement in overall quality, efficiency of patient care, reduction of errors, enhanced monitoring of drug therapy, better daily workflow management, easy access of clinical data, legibility of notes, improved problem and medication lists, and better preventive care documentation [6].

However, several challenges and risks also emerged, concerning professional’s time management and efficiency and associated burnout risk [7]. In spite of potential hazards, EHR proficiency is now an established and necessary competency for any physician [8].

However, a significant change in context due to the introduction of digital technology created a triangular relationship among physician, patient and technology [9].

This paper aims to shed light on the chronology behind caregiving for example, if physicians view data from EHR previous to medical history taking or inversely. The context in which the usage of EHR for history taking develops and how the data is managed by physicians and patients. How conflict of information between patient and its’ sources is approached and current challenges in EHR usage. In addition to tools used in EHR to gather, organize and record patient’s medical history.

To examine how EHR and medical history relate, the authors conducted a systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) guidelines to (1) identify changes in physician care giving, with focus on medical history taking, with the use of EHR in the workspace and (2) summarize the impact of EHR on medical history taking, regarding improvements in protocol or guidelines.

2. Methods

This project did not meet the criteria for submission to local institutional review board appreciation, since all data was published and publicly available.

3. Results

Our electronic search yielded 170 citations, 162 through PubMed and Cochrane databases and 8 additional results through hand-searching potential studies reference lists, of which 18 studies met inclusion criteria for qualitative synthesis. Figure 1 summarizes the process through which studies were excluded. During level 1 screening a total of 82 studies were excluded. 63 were found to be unrelated to topic and 19 focused solely on EHR but not on physicians, residents or medical students.

During level 2 screening 11 studies did not meet inclusion criteria, 2 of them focused on nurses, 4 were unrelated directly or indirectly to medical history taking and 5 of them didn’t mention changes, impacts or modifications in workflow or clinical practice dynamic with EHR usage regarding documentation, retrieval, gathering or recording information.

Different studies designs were included as a multitude of approaches resulted in distinctive and variable views, such as systematic reviews, observational and experimental studies, policy position paper and short communications in press.

Table 2 summarizes the results, study designs, population and intervention were assessed and are presented, outcomes, risk of bias and limitations were assessed as well. Study findings were categorized and are presented divided among 4 subcategories “EHR vs Paper-based systems”, “Chronology and Context”, “Data management and tools” and “Challenges in use and information conflict management”.

4. Discussion

We identified eighteen studies [10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28] describing directly or indirectly many factors detailing the relation between digital health and anamnesis. As Electronic Health Records present multifaceted interface, the possibilities of influencing clinical practice, particularly focusing medical history taking and anamnesis, are as numerous as the possible tools and functionalities which can be implemented.

Multiple changes in clinical practice have been introduced by EHRs. New workflows and dynamics were created as systems progressed and gained new functions, abilities and collected large amounts of data. The latter is now better organized and ready for use than in previous paper-based records.

Some studies showed that between paper-based systems and EHR, electronic recording took longer than paper records. One study found that electronic charting for emergency department patients with non-traumatic chest pain was significantly slower than the standard paper-based system [15]. Another postulated that an increase in electronic chart review may be associated with increased data volume in EHR compared to paper systems [10]. Sometimes expectations of physicians and healthcare professionals regarding EHR usage, data quality and data reuse are not met, however one study found that the overall perception of users in the formerly paper- based center improved or remained stable [13]. Widespread consensus is that there is still room for improvement in EHR development so that it can improve into a more user-friendly and data management system. In addition to possible system improvement, EHR competency is a necessary skill [8] that is both acquirable and teachable. As studies successfully implemented a teaching method of EHR-communication skills [17, 25], being computer literate and skilled is also a major component of physician’s adaptability to EHR [11, 12].

Changes in clinical practice context were made during EHR implementation, modifying the dynamic of patient-doctor relationship towards a system with three components with the addiction of technology [11].

However, studies have shown that the impact felt by the patient was more towards indifference to its effect or report neutral to positive levels of satisfaction with their care [11] and that there is no evidence that the EHR has affected physicians’ ability to empathize with patients [11]. In conclusion, they did not sense a decrease in empathetic engagement from the care giver while pointing out that physicians could be potentially more aware of their past medical information. Physician’s opinions are more diverse as multiple studies have shown that some are skeptical towards EHR implementation and its impact in doctor-patient relationship. They sense negative effect of EHR on the patient–provider connection [17]. Since more time is spent on documentation than with the patient [24] and physicians are required to multitask while attending to the patient [17, 22, 24].

With these changes in context setting, new workflows and dynamics have been created. Some studies show that EHR review is done first in a new-patient, leading then the professional to be more informed when first giving care [10, 17]. However there has been recorded potential personal and provider biases regarding what one could call the “virtual image of the patient”. The virtual construct of a patient history based on information collected through technological means of data retrieving from EHRs done by a physician or other care provider. Possibly misidentifying or disregarding important aspects of medical history taking and physical examination [11, 16].

As such, data management is paramount for the existence of an EHR with accurate and reliable information. This is a major concern according to physicians [22]. Regarding EHR accuracy of information, multiple studies regard “copy and paste” as a liability to stored information since it is easy to perpetuate errors without noticing. As one study stated “The pervasive use of the “copy and paste” function has negatively affected the quality of many patient records, with inaccurate or outdated information often carried forward.” [18]. However, it is possible to mitigate these risks by developing EHR functions that record if data was copied and the original source [14]. In fact, EHR templates have been proven to improve care management. In one study an increase in rates of documentation of obesity was associated with the use of a standardized EHR template [21], which lead to improved nutritional and physical activity counseling.

It is also possible to improve and assess data management skills. Developing awareness and teaching methods is important so that it is progressively possible to observe an improvement in data quality. One study successfully implemented an EHR objective structured clinical examination (EHR-OSCE) for clerkships students. It showed that students perform well in EHR-related communication skills, but found skill shortages in data management [29].

Many clinical practice assistant tools emerged throughout the years. One study made a systematic review of family history tools, it showed that they improve identification of patients with high risk of disease [16]. Although it also detailed that more research is need in this topic. It stated that linking family history tools to clinical guidelines is necessary to enable recommendations for management by the family physician [19]. Another showed that direct data input by patients can be more accurate and aid in physician’s medical history taking [11]. It was also more frequent to observe new information added in sexual history as patients find comfort in the nonjudgmental qualities of computer-based history taking. As it suggests that it is less likely to collect information that is viewed as taboo or stigmatized [11, 23].

As seen before conflicts of information provided by the patient and stored in EHR may arise. It is important that physicians are aware of potential errors that may afflict documentation as unsafe practices, such as copy and paste, and provider biases can influence both the collection and the recording of patient data [11]. In addition to, patient-facing technologies, may also present challenges including generating inaccurate or less granular information [23].

Challenges in use of EHR may result from patients being dependent on health or computer literacy when completing tools devised to facilitate medical history taking [11]. Care giving professionals have also been found to be dependent on computer competency [11] and training to provide care in a timely matter. One study found that residents wrote significantly longer notes than the average hospitalist. As reflective of the purpose of their notes, considering residents are encouraged to detail their thought process [20]. This is compatible with barriers to information gathering detailed in one study where pediatricians perceived inaccurate, excessive and poorly displayed information as increasing EHR chart review time [10]. As detailed in the same study “the veracity and accessibility of information in the electronic record can have a significant impact on the quality and efficiency of patient care.” [10]. Solutions to those reside in physicians, residents and medical students training and increase in proficiency and computer literacy. Doctor-patient relationship may improve with EHR-communication skills training.

Our small sample size is likely to be associated with paucity of academic literature on EHRs and its effect on medical history taking. We attempted to mitigate this bias by including a variety of studies designs, searching using a broad set of Medical Subject Headings and hand-searching references lists.

5. Conclusion

Following a systematic review of the literature, we identified a number of studies stressing the relation between digital tools and medical history taking. In the context of increasing EHR adoption, the adaptability of the care giver is put to the test. When comparing EHR with paper-based systems, we saw that the former brings many benefits to quality of care. Physicians tend to review EHR charts prior to patient encounter. In this triadic context, patients are indifferent to EHR introduction while physicians may overcome perceived barriers with training and computer literacy improvement.

Many issues regarding documentation and data management were found to improve with progressive implementation of EHR, as new tools, templates and functions appear. We postulate that an organized and conceptualized process of Digital Medical History or, also called, “Digital Anamnesis” bears the potential to greatly improve the quality of information gathered. This will in turn ensure better patient safety and improve professional satisfaction through decreased workload and lesser risk of burnout. Education in this new, possible hybrid process of combining classic and digital means of obtain medical history may need to be conceived in Medical Schools and Residency/Internship programs. Future work can pursue a deeper analysis of available literature in this important field of classic and digital medical history taking and empirical work can look at educational needs of medical students and junior physicians.