A 7-Domain Framework That Can Bridge Clinical Care, Health Systems Science, and Health Equity: Lessons From the H&P 360

Abstract

The H&P 360 is a reconceptualized history and physical (H&P), which clinical medical students have reported reveals clinically relevant information not elicited by the traditional H&P, informs care planning, promotes interprofessional team care, and enhances patient rapport. In addition to the traditional checklist focused on patients’ medical conditions, the H&P 360 includes prompts for gathering limited but critical information in 6 other domains directly relevant to patients’ overall health—patient values, goals, and priorities; mental health; behavioral health; social support; living environment and resources; and function. Clinicians are thus reminded to elicit relevant information from each domain appropriate to the context of each clinical encounter.

As health systems explore ways to identify and address social drivers of health, medical schools are rapidly expanding curricula beyond biomedical conditions, as reflected in the multifaceted health systems science curriculum. Many of today’s medical students struggle to find connections among the core tasks of mastering biomedical clinical medicine, their evolving professional identity and career trajectory, and addressing systemic and societal barriers to population health.

The authors argue that the 7-domain framework can serve as a conceptual bridge that links the care of individual patients with topics in the health systems science curriculum to promote health equity. The authors provide illustrative examples of the 7 domains as an organizing lens that can promote curiosity and understanding of seemingly disparate topics, such as interpersonal violence, social drivers of health, and structural racism, as well as help students expand and define their professional identities as physicians beyond diagnosis and treatment of biomedical conditions.

The authors invite discussion and experimentation around the use of the 7-domain framework in teaching, assessment, and curriculum development and point to resources for clinical educators for teaching and measuring the effects of the H&P 360 on learners, preceptors, and patients.

A modified history and physical (H&P) termed the H&P 360 has recently been developed and tested by an American Medical Association (AMA) working group on chronic disease prevention and management through the Accelerating Change in Medical Education initiative.¹ When using the H&P 360, learners adopt a 7-domain framework in which, along with the traditional checklist focused on patients’ medical conditions, limited but critical information is gathered in 6 domains directly relevant to the health of individual patients.^2,3 In performing this work, members of the working group have been struck with the relevance of the 7 domains to broader dimensions of health care, as well as with students’ struggles to incorporate the disparate topics of the health systems science curriculum into their clinical learning and growing professional identities. In this article, we argue that the 7-domain framework can serve as a conceptual bridge between clinical care, health systems science, and health equity that can help learners see the relevance of and be curious about health systems issues by connecting them with their care of individual patients.

The H&P 360 and the 7-Domain Framework

The H&P 360, an update of the traditional H&P, was developed as an information-gathering template for clinicians. While retaining the basic structure of the traditional history-taking template that focuses on diagnosing biomedical conditions (one domain), the H&P 360 also prompts clinicians to gather limited but relevant information from 6 other domains: patient values, goals, and priorities; mental health; behavioral health; social support; living environment and resources; and function. The premises for the 7-domain framework of the H&P 360 are that select (not comprehensive) information from each domain can significantly impact clinical care, that this information differs across patients, and that prompts will promote the identification of barriers and promoters of health within routine clinical care. Since most clinical encounters are time-limited, the 7-domain framework can guide data collection over multiple encounters, not necessarily at a single visit. The H&P 360, like the traditional H&P, is not a comprehensive screener for social drivers of health. Its core purpose is to routinely make visible socioeconomic and behavioral factors that influence patients’ health outcomes, while fitting within the time and practice constraints of busy clinicians.

These 7 domains have been identified in comprehensive assessment frameworks designed for holistic patient care in geriatrics, chronic mental health care, and care of homeless persons, although they may be labeled or divided differently in these other frameworks.² The commonality of the domains suggests that they are universal (apply to all patients) and comprehensive (include all clinically relevant aspects of health and disease). Over the past 15 years, the 7 domains have been found to be relevant and stable in a variety of education and health care settings^4,5 and inform the basic structure of the H&P 360.^2,3

To date, the H&P 360 has served as a data collection and organizing framework describing characteristics of individual patients at a single point in time (the present). In controlled studies, compared to the traditional H&P, the H&P 360 yielded more information across domains and is perceived by students to add clinically valuable information, while enhancing team-based care.^2,3 In work currently underway, the H&P 360 is being applied in a variety of inpatient and outpatient settings and across learner levels.

In our work with the H&P 360 in individual patient encounters, however, the potential usefulness of the 7-domain framework across a broad spectrum of education and health care contexts seemed evident. We were particularly intrigued by the potential use of the 7 domains as a conceptual bridge that could help physician learners move seamlessly from the care of individual patients to system-level thinking in a variety of contexts, but in particular for promoting health equity. As an illustrative example, we envision a student seeing a patient who states they cannot afford their medications (living environment and resources domain) repeatedly asking why—(why 1) income is limited relative to the cost of medications, (why 2) no or limited health insurance, (why 3) employer-based or marketplace insurance offers limited medication coverage, and (why 4) differential access to employment by race—to understand systems and the root causes of patients’ health and health care. Here we outline some potential applications of the 7-domain framework in education and health care as areas for further investigation. Our goal is to stimulate discussion of an approach—particularly among physician educators—for connecting clinical encounters to physicians’ roles and responsibilities in addressing the root causes of patients’ illness and health at the individual, health system, and societal levels.

The 7-Domain Framework and the Work of Physicians

The roles and responsibilities of physicians—and therefore the scope of medical school curricula—are rapidly evolving and intensely debated.^6–8 Topic areas in this evolution include integrating behavioral and social drivers of health into routine clinical care⁸; developing skills related to health systems science, including population health and health systems improvement⁹; and collaborating with communities, the government, and social services to move upstream to address social drivers of health and structural inequities and their root causes.¹⁰ Thus, the potential breadth and depth of the evolving medical school curriculum is vast and has at times been described as feeling irrelevant to the “real work” of being a doctor.⁷ Educators struggle to include ever-expanding content into an increasingly compressed curriculum, while students struggle to define their roles and responsibilities as physicians in promoting health system and social reforms.

We hypothesize that by keeping the 7 domains visible through all dimensions of physician learning, conceptual bridges will be built that connect patient care with broader aspects of health, making it easier for physicians to identify the boundaries of their professional identity beyond diagnosis and treatment of biomedical conditions. By conceptual bridge, we mean that a relatively simple domain-based framework relevant to the most essential work of physicians—the care of individual patients—can be used to help understand and illuminate broader aspects of physicians’ roles in treating disease and promoting health among populations and society. Figure 1 describes how these conceptual bridges might work in 4 areas—clinical encounters; past events; future events; and teaching, assessment, and curriculum development.

Figure 1.

Schematic showing how the 7-domain framework used in the H&P 360^2,3 might work in 4 areas of physician practice in the 21st century: (Panel A) clinical encounters; (Panel B) past events; (Panel C) future events; and (Panel D) teaching, assessment, and curriculum development. The H&P 360 was developed and tested by the American Medical Association Chronic Disease Prevention and Management and H&P 360 Working Group. It updates the traditional history and physical (H&P) to include 6 additional domains. The 7 domains are listed in the center of the figure. Abbreviation: ACEs, adverse childhood events.

Clinical encounters (Figure 1a)

In the care of individual patients during clinical encounters, the H&P 360 incorporates the 7 domains to elicit and manage information on behavioral and social drivers of health that critically influence patients’ clinical outcomes. To date, clinical medical students have reported that the H&P 360 helps reveal clinically relevant information not elicited by the traditional H&P, informs care planning, promotes interprofessional team care, and enhances patient rapport.^2,3 Representative comments from senior medical students using the H&P 360 in 2020 include: “[The H&P 360] … facilitated (a) stronger patient provider relationship, helped create comprehensive problem list” and “I think it provides a framework for getting to know the patient better and helps to connect with them on a stronger and more genuine level.”¹¹ We posit that the H&P 360 also promotes consciousness of health equity in patient encounters and may stimulate actionable plans to address barriers to health and health care.

Past events (Figure 1b)

We also suggest that, just as the traditional history asks about past events (e.g., past medical history, occupational history) to elucidate current biomedical conditions, the 7-domain framework is an organizing lens to illuminate past events relevant to patients’ overall health. Here, the point-in-time orientation for information gathering in the H&P 360 takes on a temporal component to elicit narratives from the past that are critical to patient care. For example, considering past social support in patient encounters could prompt questions about interpersonal violence or adverse childhood events, while considering past living environment and resources could trigger investigation of past trauma related to immigration or experiences of racism.

We also propose that the domains could prompt understanding of relevant past events related to health care, communities, and society. For example, patients’ distrust of the health system (a main influence on health behavior) can be illuminated by understanding the history of racial violence and oppression by health systems and academic institutions among Black communities^12–14 and Native peoples.¹⁵ Information on patients’ current living environment and resources, such as food, transportation, or health insurance, can trigger inquiry into the demographics, economic environment, and employment opportunities of local communities and their root causes. At a societal level, the 7 domains could organize thinking around structural oppression and racism by asking, “Why and how did some patients’ array of opportunities (social, educational, or financial capital) come about, resulting in their current income, housing, health insurance, or food access?”

Future events (Figure 1c)

The domains can also guide information gathering and action related to future events along the same 4 dimensions of patient care, health care, community, and society. For example, students using the H&P 360 are prompted to explicitly include patients’ values, goals, and priorities in health care planning and are more likely to include other health professionals to mobilize an interprofessional team.² As another example, patient values, goals, and priorities and living environment and resources viewed through a lens focused on the future might prompt often-neglected conversations about the goals of care and future living environments, respectively, as patients’ health and function change over time.

In health systems and communities, comprehensive planning for health is benefitted by considering each domain. For example, patient values, goals, and priorities can motivate health systems to elicit coincident or competing goals of communities through community health needs assessments. Many health systems are now asking patients for individual needs related to social drivers of health, but data elements vary over areas that are as disparate as social isolation, domestic violence, food insecurity, and precarious housing,^16–18 and there may be unintended consequences of screening for social drivers of health.⁸ The 7 domains might serve to organize information on social drivers of health to better inform community-wide interventions to address social or environmental risk factors. For example, the mental health domain can help focus on gaps and opportunities for mental health care throughout a community and the living environment and resources domain could shed light on needs to preserve or build safe and secure housing and green spaces or to ensure infrastructure to enable a well-functioning community. This latter domain is already receiving increased attention as health systems explore ways to influence social determinants of health, such as housing, food security, and transportation.^19,20

At the societal level, physicians, other health care professionals, and health systems have a role in advocating for reforms in policies that determine equitable access to housing, employment, and education as well as in advocating for initiatives to protect and promote healthy living environments that are threatened by global climate change.²¹ Health systems can examine and reform leadership, policies, and practices to ensure they represent and address the priorities of the diverse range of patients and communities they serve.

Teaching, assessment, and curriculum development (Figure 1d)

We posit that the 7-domain framework can facilitate teaching, assessment, and curriculum development. In patient-based clinical teaching, the domains provide an organizational framework for learning core clinical skills. For example, eliciting patient values, goals, and priorities can be a springboard for learning rapport-building and communication skills or integrating patients’ goals into care planning. Assessing and facilitating behavioral health can open a path to motivational interviewing or identifying and managing personality disorders. In probing patients’ social support systems, learners can develop skills in identifying and addressing interpersonal violence or caregiver stress. Inquiries into living environment and resources can bring up topics such as insurance status, medication access, or housing or food security; their root causes; and resources to address them.

In clinical teaching encounters, educators can use the domain framework to ask: what are the priority learning areas within a given domain for this learning encounter and what do I know about this learner’s skills across all 7 domains? In this context, each domain can link to a set of assessment goals for a learner or group of learners. Preceptors and schools can choose specific skills within each domain for assessment to help ensure individuals and groups of learners are assessed across a full range of types of competencies (e.g., medical diagnosis [biomedical conditions], diagnosing and managing mental health or substance use disorders [mental health], motivational interviewing [behavioral health], interpersonal violence and elder abuse [social support], knowledge and use of local food banks [living environment and resources], interprofessional care [multiple domains]) without missing or underweighting critical competencies.

As a guide to curriculum development, the 7 domains may be most immediately applicable as an organizational framework for teaching the health systems science curriculum (see below).

Health Systems Science

Teaching students in areas beyond biomedical conditions is both essential and challenging as health systems and medical schools seek to address such diverse topics as health equity and health effects of structural racism, quality of care, and planetary health. In recent years, substantial progress has been made in defining nonclinical domains relevant to all medical professionals through the AMA’s health systems science curriculum,²² a multifaceted curriculum that includes topics as diverse as leadership, ethics and legal issues, and health care policy and economics.⁹ Many of today’s medical students struggle to find connections among the core tasks of mastering biomedical clinical medicine, their evolving professional identity and career trajectory, and addressing systemic and societal barriers to population health.^23,24 We posit that the 7-domain framework could help bridge this gap by providing a set of conceptual signposts throughout the health systems science curriculum (Figure 2). For example, health care policy and economics could be presented as a set of topics addressing the root causes of living environment (e.g., housing) and resources (e.g., insurance, employment) for health care. Value in health care could be centered on discussions of competing patient values, goals, and priorities (e.g., of value to whom? defined by whom?) at societal, political, and community levels. Behavioral health and function, considered at a population level, could include relationships between health systems and communities to highlight systemic racism and disenfranchisement by the health system of racially defined populations (i.e., could help elucidate health care structure and process and health system improvement). As students are challenged to elucidate connections between the care of individual patients and health systems science, the 7 domains could serve as an organizing framework connecting patients’ current conditions with health systems, community, and societal factors that influence them. Illustrative examples of how health systems science topics link to the 7 domains are provided in Table 1.

Figure 2.

Schematic showing how the 7-domain framework used in the H&P 360^2,3 could help bridge the gap between clinical care and health systems science (HSS). The H&P 360 was developed and tested by the American Medical Association (AMA) Chronic Disease Prevention and Management and H&P 360 Working Group. It updates the traditional history and physical (H&P) with 6 additional domains. The 7 domains are listed in the center of the figure. Used with permission of the American Medical Association. © Copyright American Medical Association (2021–2022). All rights reserved.

Table 1.

Examples of Health Systems Science Topics Linked to the 7-Domain Framework Used in the H&P 360^2,3,a

Responses to Concerns About the H&P 360

We are discomfited by the challenges our students face in mastering expanding and diffuse topics as they hone their personal and professional identities. Students who feel an urgency to address the health inequities and racism that infuse society and health systems can be particularly distressed. Application of the 7-domain framework as a conceptual bridge between patient care and health systems issues may help alleviate these tensions by providing a more coherent road map to understanding and addressing challenges in health systems, communities, and society.

In our dialogues with colleagues about the 7-domain framework, many saw its immediate relevance, while others offered critical observations. Here we discuss some of the critical concerns we have heard to promote further application and investigation of the 7 domains in medical education and health care.

Domains versus checklists

Concerns have been raised that the usefulness of the 7-domain framework in physicians’ practice is limited, as there is too little time in patient encounters to address anything beyond patients’ biomedical conditions. We are sympathetic to this concern, but note it is based on the historical conception of the H&P as a checklist of single items covering a range of topics. In distinction, the H&P 360 is domain-based, retaining the checklist elements designed to diagnose biomedical conditions, while adding prompts to address other areas that are clinically relevant. For example, we are better clinicians when we remember to periodically check in with our patients on their health and life priorities (patient values, goals, and priorities), whether they are securely housed or have financial concerns about retirement (living environment and resources), or how they spend their days (function). We (authors) often run through the 7 domains as we prepare to see patients, even those we know well, and pick 1 or 2 topics to gather more background information on during a visit (e.g., When did I last check in with this patient on their long-term goals of care?). This process often opens new avenues in managing chronic medical conditions and helps center the visit on issues most likely to affect patient well-being and health outcomes.

Effects on learners

Concerns about adopting the H&P 360 in medical education have also been raised, despite its early successes. Concerns we have heard include that gathering information about contextual factors that influence patients’ health will overwhelm or frustrate students already challenged with the work of becoming good clinicians, frustrate or dishearten students if resources are not available to address factors that are negatively influencing patients’ health, and detract from students’ ability to master doctor–patient communication and diagnostic reasoning⁷; and that addressing social drivers of health is about health system reform rather than physicians’ daily work.²⁵

These concerns can largely be resolved by avoiding conflating the use of the 7 domains with having to run through lengthy checklists during a single encounter. A domain-based approach to contextual factors is not meant to screen for nonbiomedical factors that affect health, rather it is meant to gather relevant information systematically and longitudinally across areas that are key to health. Relevant information within specific domains, appropriate to the clinical context, may be gathered over time at multiple encounters or at an intake or annual review encounter when more in-depth data gathering is routine. The 7-domain framework is a systematic guide to this process, ensuring that areas key to patients’ health are not overlooked, and that patients’ values, goals, and priorities remain a centerpiece of care.

Work by our group and others suggests that, at least among senior students, students perceive clinical value in having a more complete picture of their patients and that they find many of the driving forces of ill health actionable once identified, especially as their identification promotes effective use of interprofessional team care.^2,3,26,27 The H&P 360 may decrease cognitive load by giving students a manageable number of categories for eliciting information that is essential for effective chronic disease management and reducing concerns that they have missed vital background information. We also suggest that by promoting the mobilization of interprofessional care teams, the 7-domain framework facilitates physicians’ ability to focus on disease diagnosis and treatment.

The 7 domains and health systems science

Concerns about applying the domains of the H&P 360 in medical education also overlook the fact that the inclusion of health systems science and population health curricula are already sources of cognitive overload that challenge students’ ability to consolidate their learning and develop their own professional pathways. The 7-domain framework is not new curricular content, but a way of tying apparently disparate parts of a fragmented curriculum into a more coherent picture. Anecdotal evidence from our group suggests that even first-year medical students, who are arguably the most dependent on checklists, become more comfortable incorporating psychosocial topics into clinical encounters when they use the 7-domain framework.

At the level of health systems, making the behavioral and social drivers of health visible motivates students, schools, and health systems to address them when possible (e.g., providing clinicians easy access to information on referral mechanisms to social services that are available in patients’ communities). Even when social drivers of health are not immediately actionable, we contend that the consequences of unawareness are far more dire (e.g., implementing care plans destined to fail, missing opportunities to motivate students to pursue careers that can drive long-term changes in health systems, promoting complacency among health systems in addressing structural sources of health inequity).

Conclusions, Next Steps, and an Invitation

In the end, we envision not so much that the 7 domains will provide a direct, point-to-point road map to the many areas key to health discussed here, but that they will become the foundational conceptual framework through which physicians understand their work. By providing a common, simple framework that includes all dimensions related to human health, physicians’ professional identities—that is, their view of their roles and responsibilities—could be developed so that they more readily integrate biomedical and nonbiomedical elements of health tailored to, and driven by, individuals’ aspirations and priorities.

Our working group is currently outlining the next steps in examining and disseminating the H&P 360. Our research goals are to examine the integration of the 7 domains into learning experiences among preclinical, clinical, and postgraduate students in a variety of clinical settings. Our research and reform agendas include faculty development on teaching and applying the H&P 360 and/or the 7-domain framework and integrating the 7 domains and H&P 360 into the electronic health record and telehealth medicine. In all of these areas, we are particularly interested in the role of domain-based thinking in identifying and addressing social influences on health, health inequity, and racism embedded in health and health care.

We also wish to make resources available for clinical educators at all medical schools to implement and expand our knowledge of the H&P 360 and thus are constructing a toolkit for teaching and measuring the effects of the H&P 360 on learners, preceptors, and patients. These resources are available through the AMA’s Chronic Disease Prevention and Management website.¹

At a broader level, we invite discussion and experimentation around the use of the 7-domain framework in teaching, assessment, and curriculum development. For example, can educators and students working in curricular areas, such as trauma informed care, LGTBQ+ care, structural competence, or health systems science, readily envision framing their curricula within the 7 domains? We also invite medical education researchers to explore the pedagogical aspects of checklist- versus domain-based learning and the potential role of domain thinking in influencing physicians’ identity and sense of professional purview. Most fundamentally, we invite colleagues to examine whether something as simple as integrating a framework of 7 domains into physicians’ everyday thinking and practice can promote trusting, fully humanized relationships between clinicians and patients, health systems and communities, and the health professions and society as a whole.

Acknowledgments: The authors wish to acknowledge the members of the American Medical Association’s (AMA’s) Chronic Disease Prevention and Management and H&P 360 Working Group whose work supported the ideas discussed in this article.