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

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