Death of the Documented History, Rise of the Patient Advocate
When clinical documentation gets overrun with auto-populated data, it’s time to redirect technology to better serve our patients.
Medical providers will no longer be required to document the history/medical interview during outpatient/office services in health records starting Jan. 1, 2021, per the 2019 Medicare Physician Fee Schedule (MPFS) final rule. This new policy is supported by the Centers for Medicare & Medicaid Services’ (CMS) Patients Over Paperwork Initiative, which seeks to reduce medical provider administrative burden and improve the healthcare experience for all participants, including patients.
Removing requirements to document the history in the health record can sound contradictory to excellent care. Sir William Osler, MD, considered to be the father of modern medicine, said, “Listen to the patient, he is telling you the diagnosis.” Osler’s words ring true today, as studies show an accurate diagnosis and effective treatment plan are likely to come from understanding the patient’s concerns and presenting symptoms.
Auto-populated Data Muddles the Patient History
Unfortunately, our current system, which rewards quantity of data rather than quality, has forced medical providers to auto-populate electronic health record (EHR) content using templates and copy-and-paste and copy-forward functions. As a result, data documented in the health record often has little to do with the patient encounter. Worse yet, auto-populated data often includes patient information that was never obtained or contradicts other statements in the health record. Two studies in medical literature showcase the poor status of health record documentation.
Study No. 1
The first article, published March 2017 in the Journal of the American Medical Association (JAMA) Ophthalmology compared what patients reported in the waiting room of a university eye clinic to what medical providers documented in the EHR.
Investigators asked patients in the waiting room to voluntarily complete a survey with eight questions that matched a screenshot from the provider’s EHR. The eight questions addressed eye concerns from “blurry vision” to “eye pain.” The questions addressed the presence/absence of each symptom using a Likert-type rating scale of severity from “very mild” to “very severe.” Investigators collected the forms before patients exited the waiting room to see the doctor. Later, researchers compared each patient’s waiting room report to the provider’s documentation in the EHR.
When patients reported “eye pain” in the waiting room, researchers found “eye pain” to be missing from documentation 29.5 percent of the time. When patients reported three or more concerns, zero charts in the entire study documented the three or more concerns. Investigators counted any mention of the eight eye concerns in the health record for the date of service. This included clicking a button next to any of the concerns in the provider’s history that identified the presence of the problem, as well as any free-text descriptions. The study revealed a poor correlation between what patients reported and what providers documented into the health record.
The JAMA eye study concluded, “These results suggest that documentation of symptoms based on EMR data may not provide a comprehensive resource for clinical practice or ‘big data’ research.”
Study No. 2
Another JAMA study, published Sept. 18, 2019, monitored medical residents in the emergency department and compared patient encounters with EHR documentation. Investigators shadowed physicians as they interacted with patients and then reviewed EHRs, with attention to the history’s review of systems (ROS) and the examination. Researchers combined audio recordings and live observation comments to best quantify what occurred during the physician-patient encounter. To score the ROS, investigators created a checklist based on CMS publications.
The study explains, “If a symptom mentioned in the encounter was not listed on the checklist, the reviewer added the symptom to the encounter’s checklist under the most relevant body system.” The study further explains, “Reviewers extracted all symptoms listed as reviewed in either the ROS or the history of present illness portions of the electronic medical record and assigned them to a body system using the same checklist as in the ROS observation measurement.”
The JAMA emergency department study found the ROS to have a 40.1 percent accuracy rate. If scribes were involved, ROS accuracy dropped to 36.7 percent. The study concluded, based on poor documentation accuracy, that “payers should consider removing financial incentives to generate lengthy documentation.”
Physician Leaders Are Called to Action
During an @SeemaCMS Twitter podcast, July 18, 2018, National Coordinator for Health Information Technology Donald Rucker, MD, was asked if eliminating provider requirements to document the history in health records would undermine patient care and efforts to create effective predictive algorithms. Rucker defended new CMS policies, calling health record documentation of the history/exam “anti-matter” and “clutter.” Citing the need for greater “signal” and less “noise,” he calls for the end of templates and copy-and-paste and copy-forward EHR functions.
A 2017 Journal of the American Osteopathic Association (JAOA) paper invited patients to complete a PreHistory (PreHx) in preparation for a medical encounter with the family doctor. Patients were sent a three-page form that included all of the near 30 history questions as defined by CMS’ 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. Upon arriving at the office, patients presented the document as a written request to amend the record per the Standards for Privacy of Individually Identifiable Health Information of 2001, commonly referred to as the HIPAA Privacy Rule. Rather than wait up to 90 days to review the patient’s request to amend, the provider followed a research protocol to accept the information immediately and use the patient’s words to populate the history component of the health record. As a result, accuracy rose to 100 percent for the chief complaint, history of present illness, status of chronic conditions/diseases, ROS, and past, family, and social histories.
Use of a PreHx allowed:
- The patient to fully disclose all their concerns and paint a comprehensive picture of their problem into the health record.
- The provider to have the entire history documented in the encounter note before entering the exam room.
- Efficient data gathering for the provider to review the patient’s story and ask deeper questions beyond the documentation guidelines and then perform a pertinent examination.
Because both the patient and provider were highly engaged, medical decision making (MDM) readily transformed into shared decision making. The study held to a 15-minute schedule for all patients and use of the PreHx permitted all charts to be completed by the end of the face-to-face visit. Per the JAOA’s research protocol, all PreHx patients received a printed copy of the entire encounter note (history, exam, MDM) at the checkout window at the end of the visit.
CMS declared for 2019 that patients and ancillary staff members may document the history into health records. This provision relieves providers of the impossible task of asking and documenting time-consuming history data and removes the temptation to auto-populate EHR content with templates and automated functions. The patient, after all — often supported by family members, friends, and caregivers — knows the subjective medical history better than anyone.
Technology Moves Toward Improving Patient Outcomes
As we enter the digital age of healthcare, we must leverage technology to improve our ability to diagnose and treat patients. EHR systems will soon provide feedback to guide us toward best practices. Imagine viewing three treatment options and seeing the expected outcome success rate next to each option? Just as Amazon can suggest another product or Netflix can suggest a movie, EHR systems will soon interact with the user. The data in EHR systems, however, must be accurate.
The death of the provider-documented history should not be mourned. For the provider, we are relieving stenography and basic data entry duties in favor of maximizing critical thinking and decision making. For patients, the new rule empowers individuals to control the narrative documented in their health record. Fostering the patient-provider relationship, new policies encourage patients to be heard and providers to understand. Death of the provider-generated history gives rise to patients being their own advocate, ushering a new age in healthcare.
Silverman, ME, Murray TJ, Bryan CS, “The Quotable Osler,” American College of Physicians, 2008, p98
Federal Register, 2019 Medicare Physician Fee Schedule final rule, Nov. 23, 2018, www.federalregister.gov/public-inspection/2018/11/23
JAMA Ophthalmology, “Agreement of Ocular Symptoms Reporting Between Patient-Reported Outcomes and Medical Records, March 2017, www.ncbi.nlm.nih.gov/pubmed/28125754,
JAMA, “Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior?” Sept. 18, 2019, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751388
JAOA, “Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law, 2017, https://jaoa.org/article.aspx?articleid=2599978
CMS 1995 and 1997 Documentation Guidelines for Evaluation and Management: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
HIPAA Privacy Rule, The Standards for Privacy of Individually Identifiable Health Information of 2001, 45 CFR § 164.526
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