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COMMENT TO CMS: Do Not Remove History and Examination Documentation Requirements

A new Centers for Medicare and Medicaid Services (CMS) proposal suggests removing documentation requirements for the History and Examination components of a medical encounter. [i] [ii] CMS rationalizes the change because 1995 and 1997 Evaluation and Management Guidelines are “administratively burdensome” and “too complex.” Rather than mandate documentation of the History and Exam, CMS proposes allowing medical providers the ability to record whatever they “feel is appropriate.” I believe this proposal will lead to bad patient care and undermine our federal strategic information technology plan.
Admittedly, medical record documentation is dreadful. Very often, what is documented has little to do with the reason the patient seeks medical care. A recent research publication in JAMA Ophthalmology compared what the patient reported in the waiting room to what the doctor, moments later, documented in the electronic health record (EHR).[iii] Investigators found a disturbing difference between what the patient reported and what was written in the medical record.
In the JAMA study, conducted at the University of Michigan’s Kellogg Eye Center, patients were asked to complete a one-page questionnaire while in the waiting room. The form highlighted eight problems from “eye pain” to “blurry vision.” Patients indicated the presence and severity of each eye concern with a Likert scale of responses from “none” to “very severe.” The form was collected before the patient left the waiting room to see the doctor.
At a later date, JAMA researchers compared the patient’s report to what was documented in the EHR. The correlation was poor. If a patient indicated having eye pain, for example, researchers found “eye pain” to be missing from the EHR 26.5 percent of the time. If a patient had three or more complaints, no chart in the study correlated. Because medical records poorly tracked the patient’s subjective story, the JAMA study seems to support the CMS proposed rule to discard requirements for documentation.
The History, as defined and structured by 1995 and 1997 Evaluation and Management Guidelines, translates to approximately 30 questions.[iv] The History starts with the chief complaint (cc), which is the reason why the patient seeks medical care. “Eye pain,” for example, is a chief complaint. The History then expands to include the History of Present Illness (HPI). The HPI is the “who, what, when, where” describing the patient’s concern and includes: location, quality, severity, duration, timing, context, modifying factors, associated signs & symptoms. Quality, for example, asks what the problem looks or feels like. Modifying factors asks what makes the problem better or worse.
In addition to the cc and HPI, Status of Chronic Condition/Disease allows for an update of a chronic problem. A patient with Diabetes mellitus, for example, may offer results of daily blood glucose testing, dietary habits and exercise. The patient may also discuss adherence to medication and any possible side effects.
The History is further revealed with Review of Systems (ROS). This is a head to toe/mind-body inventory with eleven components: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, endocrine, psychiatric, hematologic/lymphatic, allergy/immunologic. If a patient is seen for chronic treatment of hypertension and also experiences leg swelling, then leg edema could be indicated in the ROS.
Lastly, the History includes Past Family Social History (PFSH). This category includes prior illnesses and surgeries, changes in lifestyle and family health history. This category also includes the medication and allergy lists. If a patient has a mother and sister with breast cancer, PFSH is where it can be documented.
The History does not contain difficult questions. Most patients can readily explain their concerns with details, such as, “How long it has occurred?” (duration), and “How bad it is on a scale from 0 to 10?” (severity). The problem, however, is how can a medical provider ask 30 questions, wait for a response to each, and then type/dictate results into the computer in the span of a 15-minute schedule?
One solution is to allow the patient to answer all History questions in preparation for a medical encounter. Though E/M Documentation Guidelines limit who can obtain a History, federal laws permit the patient to author their own History and have it recorded as part of the medical record. This right is conferred by The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) which became a final rule of HIPAA in 2001 [45 C.F.R. § 164.526].[v] [vi]
A research study published in JAOA accommodated a patient’s federal right to co-author the medical record and studied the effects.[vii] In this study, patients completed a PreHistory that was sent to them one-week in advance of a scheduled visit with the family doctor. The PreHistory is a two and one-half page paper form that replicates the near 30 questions as defined and structured by E/M Guidelines.[viii] Patients were encouraged to reflect over the questions and complete the form with the help of a family member, friend or caregiver.
JAOA researchers created a process where patients submitted their PreHistory at the check-in window upon arriving for the family doctor visit. Officially, patients submitted their PreHistory as a written request to amend the record in accordance with the HIPAA Privacy Rule. In addition, the medical provider accepted the PreHistory as Patient Generated Health Data (PGHD) in accordance with the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.[ix] [x]
In the JAOA study, the patient’s Prehistory was scanned into the EHR as a professional document file (pdf) and the content was transcribed into the appropriate fields in the History component of the encounter note. As a result, the patient’s entire History was documented in the EHR before the doctor entered the examination room. The research process required a staff member labor to transcribe information from the PreHx into the EHR. This task could be eliminated by having a PreHistory option in the patient portal that could automatically populate the encounter note History.
The doctor in the JAOA study (MJW) entered the room, greeted the patient, and then read the patient’s subjective History as documented in the EHR. In less than a minute, the doctor was able to understand why the patient was seeking medical care. The doctor was able to reaffirm what he read by asking the patient, “You tell me this and this are going on?” This led to a few more detailed questions, then a pertinent examination. Because the patient and doctor were both highly engaged, medical decision making readily transformed to shared decision-making.
Accommodating the patient’s PreHistory increased efficiency because all documentation was complete by the end of each face-to-face visit. At the checkout window after the PreHistory visit, each patient was given a paper copy of the encounter note from the EHR. Patients were instructed to go home, read their medical record, and score their experience with an anonymous survey. Patients reported feeling better heard and understood by submitting a PreHistory. Many appreciated having time to reflect over each question as opposed to rapid-fire questioning during a typical medical encounter. Participants rated their experience as a patient with a satisfaction score of 97 percent.
While the JAMA study struggled to accurately document the patient’s chief complaint, the JAOA study populated the entire History component of the medical record with accurate and detailed patient information. For the investigators in the JAOA study, medical record documentation was not administratively burdensome or too complex as the patient and provider worked together to author EHR content.
The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) allocated $25.9 billion to be paid to doctors and health systems as a financial incentive to digitalize medical information from written paper charts to electronic health records.[xi] As part of our federal information technology strategic plan, digitalized records should allow for the identification of best practices and the formulation of predictive algorithms. As a result, we should expect better patient care as healthcare quality, cost, and satisfaction improve.
Although most doctors and health systems have adopted EHRs, inaccuracy of medical records is causing problems. IBM supercomputer Watson recently ceased on a “promise to transform cancer care with the help of artificial intelligence” with MD Anderson Cancer Center at the University of Texas. After spending $62 million and five years, auditors reported there was “little to show for it.”[xii] Researchers determined Watson had trouble “reading relevant information in patient charts.” If the cancer center records looked anything like the eye center records in the JAMA study, Watson never had a chance.
Rather than eliminate documentation requirements, CMS should promote efficient and effective gathering of patient data. As the JAOA study shows, patients are willing and able to co-author the History component of the medical record. Patients are also capable of reviewing their medical records after encounters to assure for accuracy and proper content.
I oppose CMS’s proposal to eliminate medical record documentation requirements. As we enter the digital age of healthcare, patient data is paramount. Removing documentation requirements rebuffs patient information, thus, sabotaging any attempts for information technology analysis. I believe with responsible patients and responsive medical providers, we can improve patient care and enable data analytics to refine healthcare quality, cost and satisfaction.
Michael J. Warner, DO, CPC, CPMA,
President, Patient Advocacy Initiatives
2017 AACOM Health Policy Fellow
[i] 2018 Physician Fee Schedule Proposed Rule, Centers for Medicare & Medicaid Services (CMS), released July 13, 2017, p. 375-376, retrieved August 18, 2017.
[ii] Verhovshek, J, “CMS Wants to Revise E/M documentation Guidelines,”, July 14, 2017, retrieved August 18, 2017
[iii] Valikodath, NG, Newman-Casey, PA, Lee, PP, et al, “Agreement of Ocular Symptom Reporting Between Patient-Reported Outcomes and Medical Records,” JAMA Ophthalmology, January 26, 2017
[iv] Evaluation and Management Services, Department of Health and Human Services, Centers for Medicare & Medicaid Services, Medicare Learning Network. August 2017, retrieved August 17, 2017 
[v] The HIPPA Privacy Rule,, retrieved August 17, 2017
[vi] Code of Federal Regulations, Subchapter C – Administrative Data Standards and Related Requirements, § 164.526, p. 778-780, retrieved August 18, 2017
[vii] Warner, MJ, Simunich, TJ, Warner, MK, Dado, J, “Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law, JAOA, February 2017, vol. 117, No. 2, p. 78-84.
[viii] PreHistory forms available for free
[ix] “What are Patient-Generated Health Data?” Consumer eHealth, April 16, 2017, retrieved August 18, 2017
[x] Medicare Program MIPS and APM proposed rule, Federal Register, Vol. 81, No. 89, May 9, 2016, p. 28222,28225, 28228.
[xi] HITECH Act Enforcement Interim Final Rule, Health Information Privacy, U.S. Department of Health & Human Services with content created by the Office for Civil Rights (OCR), June 16, 2017, retrieved August 18, 2017
[xii] Hernandez, D, “Hospital Stumbles in Bid to Teach a Computer to Treat Cancer – A University of Texas audit shows MD Anderson’s struggles to use IBM Watson in a health-care setting,” The Wall Street Journal, March 8, 2017

About Has 19 Posts

Michael Warner, DO, CPC, CPCO, CPMA, AAPC Fellow, is an associate professor at Touro University California, president of non-profit Patient Advocacy Initiatives, alternate advisor on AMA RUC, and an AAPC National Advisory Board member. At Touro, he is conducting a series of research projects with the online tool to determine evidence-based best practices to accommodate a patient-authored medical history and improve data gathering flow.

One Response to “COMMENT TO CMS: Do Not Remove History and Examination Documentation Requirements”

  1. Christina LaRosse CPC AAPC Fellow says:

    Dr. Warner,
    I reviewed your response and you are very on point with importance of collecting patient data efficiently and effectively. The presentation of an accurate medical history is the precursor to an accurate medical exam and assessment. While I agree that counting bullets and the Evaluation and Management Guidelines are often “too complex” eliminating collecting an accurate history is alarming.