Co-Author Your Medical Record With a PreHx

Co-Author Your Medical Record With a PreHx

In her new book, Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, Maya Dusenbery describes difficulties women experience when trying to be heard and understood by medical providers. As a physician and professional coder, compliance officer, and auditor, I find all patients—and especially females—are poorly heard when it comes to what is written in the medical record. Fortunately, a mechanism exists, supported by federal law, for you (as a patient) to tell your story and co-author your medical record. It is called the prehistory, or PreHx.

The HIPAA Privacy Rule (full name: Standards for Privacy of Individually Identifiable Health Information of 2001 [45 C.F.R. § 164.526]) grants each of us the ability to submit a written request to amend our medical records. A new process has emerged for patients to co-author their medical narrative and have their story documented, word-for-word, in the medical record.

To prepare for a medical encounter—whether it be a visit with your primary care provider or trip to an emergency department—you can complete a PreHx. The PreHx is a replica of the nearly 30 questions that the Centers for Medicare and Medicaid Services (CMS) has defined and structured for the patient interview, known as the History. The History, along with the Examination and Medical Decision-Making (MDM), is a key component of medical record documentation, according to 1995 & 1997 CMS Evaluation and Management Documentation Guidelines.

PreHx questions ask for a series of organized answers to detail a person’s health status and the nature of problem(s) or concern(s). “Modifying Factors,” one of the components of History of Present Illness, asks, “What makes your problem better or worse?” Answers to this question are important, and often telling of the underlying problem. For example, imagine the person with chest pain who reports “pain worsening when climbing stairs and better when at rest.” With answers to all of the interview questions, the patient’s story often makes the diagnosis obvious.

Doctors face a difficult task when conducting and documenting the history interview. During a typical face-to-face encounter, medical providers have only a few minutes to ask all of the near 30 questions, wait for the patient’s response to each, and type/dictate/write answers into the medical record. Most often, the patient’s story is summarized into a few words, or is auto-populated with a template. As emphasized by a January 2017 article in the Journal of the American Medical Association – Ophthalmology, the result is that medical records are a “poor representation of the patient’s reported problems.”

Clinical research has studied what happens when patients are invited to complete a PreHx to co-author their medical records. A PreHistory publication in the February 2017 issue of the Journal of the American Osteopathic Association found that patients who completed a PreHx in preparation for their visit felt better heard and understood. By completing all of the CMS questions in advance of the encounter, patients were able to reflect over questions and formulate answers at their own pace. At the face-to-face encounter, it took the provider 30 seconds to read the patient’s words documented in the medical record. Relieved of administrative burden, the provider was left with more time to address the patient with a few deeper questions and a pertinent examination. Because the medical record contained rich details and both patient and provider engaged, medical decision making readily transformed to shared decision making. This means both the patient and provider worked together to form a diagnosis and treatment plan. To assure accuracy and proper content of the medical record, each patient received a copy of their entire encounter note at the conclusion of the face-to-face visit.

Throughout Doing Harm, patients’ stories often are brushed off, doubted, or not believed. This results in additional suffering and delay of diagnosis, which can take years. Adding insult to injury, what the patient says is often never recorded in the medical record. The JAMA Ophth study detected a zero correlation between what is documented in electronic health records and a patient’s report, if three or more symptoms are stated.

Exercising your federal right to submit a PreHx as a written request to amend your medical record legally includes your story as part of your record. In receiving your request, the provider is permitted to use your words to populate the History part of your record. This relieves the provider of an administrative burden, and frees him or her to give more attention to you, the patient. This effective download of personal information may help the provider understand your concerns as a detailed case, and result in a faster and more accurate diagnosis.

Although federal law, guidelines, and medical research offer a means for patients to be better heard and understood, an outdated mindset continues to restrict patients into a passive role that often results in being dismissed, misdiagnosed, and remaining sick. A new mindset is poised to emerge, empowering patients to better communicate, while partnering with medical providers to capture and address concerns. The emerging mantra is “responsible patients and receptive providers.”

Doing Harm describes problems women experience when seeking medical care. To compliment the author’s advice, I’d like to add: complete a PreHx in preparation for your next medical encounter. Medical offices may also encourage their patients to do the same, which can lead to greater patient satisfaction, better patient outcomes, and improved efficiency and effectiveness for healthcare providers.

Sources

Dusenbery, M, Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, Harper Collins, March 3, 2018

Patient Advocacy Show: Episode 1: Inaccurate Health Records, YouTube, posted Oct 16, 2016

Evaluation and Management Services, Department of Health and Human Services, Centers for Medicare & Medicaid Services, Medicare Learning Network, August 2017

Valikodath, NG, et al, Agreement of Ocular Symptom Reporting Between Patient-reported Outcomes and Medical Records, JAMA Ophthalmology, January 26, 2017

Warner, MJ et al, Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law, JAOA, February 2017

Michael Warner

Michael J. Warner, DO, CPC, CPMA, CPCO, President, Patient Advocacy Initiatives, 2017 AACOM Health Policy Fellow

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Michael J. Warner, DO, CPC, CPMA, CPCO, President, Patient Advocacy Initiatives, 2017 AACOM Health Policy Fellow

2 Responses to “Co-Author Your Medical Record With a PreHx”

  1. Lynn Holt says:

    But doesn’t CMS say that the HPI has to be the work of the provider? I am so confused now. We did have our patients fill out the HPI and it populated in the note as HPI but we were told by an auditor that we can’t do that.

  2. Michael Warner, DO, CPC, CPCO, CPMA says:

    Hi Lynn,
    I apologize for not seeing your comment earlier. Your auditor is correct, per Documentation Guidelines the History of Present Illness (HPI) must be the work of the provider. Review of Systems (ROS) and Past Family Social History (PFSH) can be obtained and documented by an ancillary staff member – either by asking patients the ROS/PFSH questions or by having the patient complete a form. This information can be documented into the medical record per CMS Documentation Guidelines (1995 p. 5)[1] (1997 p. 6)[2].
    Overriding guidelines, federal laws exist allowing the patient to request to amend the medical record. The Standards for Privacy of Individually Identifiable Health Information of 2001, also known as the HIPAA Privacy Rule, give individuals the right to give written request to amend their medical records. In response, the physician/provider has up to 60 days to respond with written notice. One option, is for the physician to accept the patient’s written request immediately at the time of a face-to-face encounter and incorporate the patient’s amendment into the medical record. To fit this federal right, however, the patient’s written statement must be submitted officially as a “Request to Amend the Medical Record per the HIPAA Privacy Rule.”
    The Privacy Rule became a final rule of HIPAA with required compliance April 2003. In addition, the Medicare Access & CHIP Reauthorization Act of 2015, recognizes patient generated health data (PGHD) as part of the new physician payment model. The National Coordinator for Health Information Technology (ONC) recognizes a patient authored health history as a form of PGHD.[3] Per federal laws, receiving a patient authored History is the work of a provider and allows the entire history to be co-authored by the patient.
    Currently, many medical records have little to do with the patient’s experience with disease and healthcare. Most medical records are completed many hours and, often, many days after an encounter. I recently reviewed a patient’s medical record where the provider recorded: “Subjective patient narrative: Patient doing well. No new complaints in past 24 hours.” This phrase was repeated for 40 days in a row during the patient’s 182-day hospitalization. Nursing notes, however, described a paralyzed patient with a bone exposed sacral decubitus who was in constant pain until she died. We can do better.
    While it is easy to blame providers for poor documentation, it is also worth noting the work flow environment that we have created. Is it reasonable to expect a provider to ask 30 History questions, wait for a response to each and then type/dictate/write answers into the medical record – in a timeframe of a few minutes?
    In a world where individuals can book travel (air, hotel, vehicle), trade stocks and conduct banking transactions online, why not allow patients to prepare for a visit by completing the History? Let’s use providers as trained medical professionals and not expect them to be stenographers and basic data entry clerks. We should be paying them to work at the top of their license.
    For now, I encourage your ancillary staff to collect ROS and PFSH to relieve the provider of clerical burden. Your next step will be to encourage your patients to exercise their federal rights and become active participants in their healthcare, which I believe, includes co-authoring the History component of their medical records.
    Thank you for your reply. I hope this adds clarification. Please show this to your auditor and let me know his/her response.
    Sincerely,
    Mike
    [1] 1995 Documentation Guidelines for Evaluation and Management Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf
    [2] 1997 Documentation Guidelines for Evaluation and Management Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf
    [3] Patient Generated Health Data per The Office of the National Coordinator for Health Information Technology (ONC) https://www.healthit.gov/topic/otherhot-topics/what-are-patient-generated-health-data

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