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Comment to CMS: History Documentation Optional? Let the Patient Co-author the History

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  • August 8, 2018
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Comment to CMS: History Documentation Optional? Let the Patient Co-author the History

During a July 18, 2018 CMS Twitter™ podcast, CMS National Coordinator for Health Information Technology, Donald Rucker, M.D. defended the new CMS 2019 proposal to make documentation of the History optional for health records. He was asked, “In light of technology’s thirst for data to identify best practices and construct predictive algorithms, is it possible that eliminating or making optional, History, and Examination documentation requirements will undermine patient care and big data efforts?”[i]
Dr. Rucker explained that by making documentation optional, health records will actually improve the quality of data. He emphasized that the current use of templates to populate records with information creates mostly “noise,” thus making “signal” difficult to find. He used the words “anti-matter” and “clutter” to describe the integrity of what is documented in health records.
Dr. Rucker’s observations are well-founded in medical literature. JAMA Ophthalmology published a clinical research paper January 2017 comparing what patients reported in a university eye center waiting room to what providers, moments later, documented in the health records.[ii] Investigators found poor correlation between what patients reported versus what medical providers documented. Researchers concluded, “These results suggest that documentation of symptoms based on EMR data may not provide a comprehensive source for clinical practice or ‘big data’ research.”
As a physician, caregiver and medical forensic auditor, I have observed the non-sense of History/medical interview documentation in health records. One of my audit cases involved a paralyzed patient, with a tracheostomy and a large bone exposing sacral decubitus. During her near 200-day hospitalization which led her death, her “Patient subjective narrative” read, “Patient doing fine with no new complaints over the past 24 hours” for 40 days in a row.
“Anti-matter” is a good description of the current state of History documentation in health records. The “anti” helps explain the detrimental impact of information that misrepresents the patient’s needs and misleads anyone reviewing health records. Factitious data, reflective of auto-population templates, undermine patient care and sabotage big data analysis. As a result, we should expect poor control of healthcare quality, cost and satisfaction.
Eliminating or making the History/medical interview documentation optional, however, has unintended consequences. Unlike template driven documentation, what about History information that is accurate and detailed? What if we were able to gather accurate data, and at the same time, relieve medical providers of clerical administrative burden?
The History, as defined and structured by CMS Evaluation and Management Documentation Guidelines, is a marvelous data set of information.[iii] 1995 & 1997 guidelines define and structure nearly 30 questions that extensively illustrate a patient’s experience. The History is comprised of the Chief complaint, History of Present Illness, Status of Chronic Disease, Review of Systems and Past Family Social History. The History of Present Illness is comprised of: Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated Signs & Symptoms. These questions are similar to the “who, what, when, where, why and how” of journalism. For example, Quality asks “What does the problem look or feel like?”, while Modifying Factors asks, “What makes the problem better or worse?” For the medical provider, a review of all of these answers often makes the diagnosis obvious. For best practice analysis and big data predictive algorithm construction, this granular data is an information gold mine.
Gathering History data with intense granularity is a near impossible workflow challenge for medical providers. A recent Harris Poll presented at the Stanford Medicine EHR National Symposium June 4, 2018 showed primary care doctors spend an average of 31 minutes attending to a patient. 12 minutes are spent interacting with the patient while 8 minutes are spent interacting with the EHR during the face-to-face encounter. After working hours, an additional 11 minutes are spent documenting and completing EHR tasks.[iv] It is common for providers to spend a Saturday afternoon completing medical records for patients seen the previous week.
Workflow analysis of the Harris poll is disturbing as the 8 minutes spent with the EHR during the encounter must be focused on Medical Decision Making (MDM). In order to check-out from the face-to-face visit, diagnoses-laboratory/testing orders-referrals-medications-discharge instructions all need to be immediately documented in the health record. This leaves the 11 minutes after hours to complete History and Examination entry. This puts the provider at a disadvantage as he/she is unlikely to remember all of the details. The easiest solution is to auto-populate the health record with templates, copy & paste, cloning and copy-forward EHR functions.
After hours EHR workflow has detrimental effects on patient care. A patient with ovarian cancer, for example, may begin to experience symptoms of mild abdominal cramping and heartburn. These vague symptoms may appear trivial and easily addressed with a high fiber diet and antacid treatment. For this patient, however, it makes an enormous difference to know if her mother and sister both have ovarian cancer. If a template auto-populates “no family history of cancer” and copy forward functions maintain this statement as the truth, then we should expect to miss the patient’s diagnosis until symptoms manifest in late stages.
Without a documented History, the evolution and persistence of the patient’s symptoms can be overlooked. For the female with undiagnosed ovarian cancer, a series of medical encounters should capture the evolution and persistence of symptoms. Such documentation helps paints a full picture of the patient’s clinical scenario, thus enabling the provider to detect an underlying disease.
While CMS Proposes making the documentation of the History in health records optional, another option exists: Let’s encourage the patient to co-author the History. Published research has shown patients to be willing and able to answer all of the History questions in preparation for a medical encounter.[v] Patients in a JAOA published clinical research study completed a PreHistory (PreHx), which is a replica of the CMS History, in advance of a medical encounter. At the encounter, patients submitted their PreHistory as a written request to amend their health record per the HIPAA Privacy Rule [45 C.F.R. § 164.526]. While the Privacy Rule allows a provider up to 60-days to consider whether or not to accept the patient’s request to amend, this research protocol recognized the provider’s option to accept it immediately. This empowered the provider to use the patient’s PreHx to populate the History component of the encounter note.
With the use of a PreHx, the provider is relieved of the clerical burden of asking and recording basic questions. Research shows a provider needs only 30 seconds to review the patient’s story. This gives the provider time to ask a few detailed questions and conduct and document a pertinent examination. Because both the patient and provider are highly engaged, Medical Decision Making readily transforms into Shared Decision Making.
Patients in the JAOA PreHx study gave no advance notice of participation other than presenting their PreHx at the check-in window upon arrival at the medical encounter. Throughout the study, a 15-minute office schedule was maintained. Efficiency and effectiveness of data gathering allowed for 100% of charts to be completed by the end of the face-to-face encounter. At the check-out window, each patient received a printed copy of the finished encounter note. They were instructed to go home, read their health record, and score their experience with an anonymous survey.
Patients reported feeling “better heard and understood” by completing a PreHx and submitting it as a request to amend their health record. Individuals also felt more empowered and graded their experience as a patient with an average score of 97%.
Father of modern medicine Sir William Osler said, “Listen to the patient, he is telling you the diagnosis.”[vi] Use of a patient’s PreHx allows patients to be heard and providers to understand, with detailed documentation in the health record.
Patient Advocacy Initiatives, a Pennsylvania 501(c)(3) organization, has created a free online service to guide individuals through all the History questions at Individuals are shown written questions along with audio-video clips to help them understand each question and formulate appropriate responses. The final PreHistory (PreHx) may be printed or electronically sent to a medical provider as a request to amend the health record per federal law.
While CMS proposes dramatic changes to health record documentation requirements, now may be the time to turn to individuals to represent themselves as their own patient advocate. I invite CMS officials and MyHealthEData Initiative to consider the use of a PreHx as a practical option to facilitate patient-to-provider communication, reduce provider clerical burden and improve health record documentation.
To quench technology’s thirst for information, let’s leverage technology to help providers improve patient care while simultaneously bolstering big data efforts. Let’s unleash the digital age of healthcare and enter a new era by improving data gathering workflow. I personally invite you to take the PreHx Challenge and visit
With Sincerity and Respect,
Michael Warner, DO, CPC, CPCO, CPMA
President, Patient Advocacy Initiatives
Dr. Warner is president of Patient Advocacy Initiatives, a non-profit organization with a mission to empower individuals to co-author their health records.
[i] CMS Office E/M Proposal. Twitter™ presentation to address the CMS 2019 Medicare Fee Schedule Proposal, @SeemaCMS, July 18, 2018,
[ii] Valikodath, NG, Newman-Casey, PA, Lee, PP et al, “Agreement of Ocular Symptoms Reporting Between Patient-Reported Outcomes and Medical Records,” JAMA Ophth, Jan 2017, p. E1-7
[iii] Evaluation and Management Services, Department of Health and Human Services, Centers for Medicare & Medicaid Services, Medicare Learning Network (MLN), August 2017
[iv] EHR National Symposium – Setting a bold, new vision for electronic health records, Moderator Lloyd Monir, MD, Dean of Stanford School of Medicine, June 4, 2018,
[v] Warner, MJ, Simunich TJ, Warner, MK, Dado, J, “Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law,” JAOA, February 2017
[vi] Silverman, ME, Murray TJ, Bryan CS, “The Quotable Osler”, American College of Physicians, 2008, p. 98

Evaluation and Management – CEMC

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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.

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