Electronic Health Record Tracking of Psychosocial Care in the Context of Serious Illness: A Narrative Review.

Abstract

Objective: The electronic health record (EHR) has emerged as a fundamental tool but has focused on physical care delivery. Psychosocial screenings and interventions are central to palliative care that supports whole person care models; however, EHR innovations to capture psychosocial care have not been optimized. Material and Methods: A narrative review was conducted from 2009 to March 2023. EMBASE, PubMed, and PsychINFO were queried to identify articles that discussed EHR tracking of psychosocial care in palliative care. Results: Eight articles met inclusion criteria representing a broad range of works in palliative care. Three themes emerged in the narrative review: (a) quality improvement strategy to support EHR tracking in collaboration with key stakeholders, (b) clarification of psychosocial domains for documentation and measurement, and (c) lack of standardization in data collection tools and processes. Discussion: This narrative review contributes to a limited body of literature on EHR extraction of complex sources of distress in palliative care. The designation of four domains (social history and distress, psychological symptoms, spiritual needs, and patients' goals and preferences) defines psychosocial practice aligned with palliative care quality metrics. Recommendations highlight the importance of shared priorities and collaboration with key stakeholders to fully execute on the clinical utility of EHRs. Future work will continue to evaluate data collection tools and systematic approaches to capture psychological needs and social environment and its impact on health outcomes and quality of life. Conclusion: This review will expand on opportunities for automated reporting of psychosocial care in the context of seriously ill.