Physician-Patient Encounters The Physician Perspective

1. Physician-Patient EncountersThe Physician Perspective Michael Stearns, MD, CPC HIT Consultant

2. High Level Physician Goals • Develop a rapport with the patient • Establish credibility with the patient • Establish the reliability of the patient • Gather information • From the history • From the examination • From test results • From reports from other providers • Get through the examination efficiently • Get paid, if surgical get cases… • Don’t get sued • Don’t become subjected to a negative audit • Have the patient say good things about you in the community, in particular to the physician who referred the patient to you

3. Develop a rapport with the patient • Be polite and professional • Not too reserved • Not too friendly • Appear knowledgeable • Patient may know more about a disease than you do, e.g., if they have been performing on-line research • Keep the patient on task, but interrupt them as little as possible • Can be very challenging…

4. Establish Credibility with the Patient • Be a good listener • EHRs can interfere with this process • Demonstrate familiarity with their complaints and ask insightful questions • Communicate in a way they can easily understand, without coming across as patronizing…

5. Establish the Reliability of the Patient • In some cases you need to interpret information that is provided by the patient • Secondary gain (may be a factor, such as what may be seen for potential disability when there is insurance) • Psychological issues • Embellishment tied to: • Fears that underlying condition is serious in nature • Fears that they will not be taken seriously unless they “amplify” the severity of their symptoms

6. Prioritize Nature of Visit • Use the history, physical and the results of diagnostic studies • Form an impression of what might be influencing the patient’s health • Identify potential emergency conditions • Sometimes seconds matter • Focus on conditions that can be treated first • Be very wary of making assumptions that could lead to misdiagnosis

7. Chief Complaint • Typically a brief statement that starts the note • Includes: • Background demographics • Some background medical information • Reason they are being seen, often in the patient’s own words • For example: • The patient is a 44-year-old white male with a history of hypertension and diabetes who presents with “numbness in my toes.” • There are multiple variations as to how a CC is structured • Classic description is “The reason why the patient is being seen in their own words” • Documentation guidelines (for reimbursement) state that a CC must be present, but it can be part of the HPI.

8. History of Present Illness • Basically the story behind the visit • 80% of anydiagnosis is made from the HPI • Iterative and interactive process • Series of questions and answers • Follows logical course • Requires expert knowledge of how diseases present • Physician may develop a short list of diagnoses (in their mind) that he/she is considering • Responses to questions drive next question • Somewhat algorithmic • Eliminate some conditions • Confirm others • Gives weighting to certain conditions over others in many cases

9. History of Present Illness (2) • May include relevant past medical information • Relevant medications • Responses to prior treatments • Underlying diseases • Prior injuries or events (e.g., trauma) • Family history • Social history

10. History of Present Illness (3) • Summary of relevant recent events • Recent hospitalizations • Recent surgeries • Prior evaluations by other providers • Stressors that could influence health • E.g., Work-related stress

11. History of Present Illness (4) • HPI documentation goals • Document information for purely clinical use • Reference notes for point of care use • Future visits • Information to be used for care at other locations • Medicolegal documentation • Demonstrate that the standard of care was met via documentation • Be wary of template defaults and cloning of information • Reimbursement purposes • HPI heavily influences coding and reimbursement • Need 1-4 HPI elements OR 3 chronic diseases and their statuses • Used to determine E&M level of service

12. The HPI and EHRs • Enter complex information and overcome natural language challenges • Free text entry via voice recognition, typing or other methods • However, this usually results in the loss of structured data (also called discrete data and/or codified data) • May be offset by NLP and automated coding • Templates/Macros popular in EHRs • Need to capture as many potential questions as possible through drop down lists with branches • Huge amount of potential information could be needed • HPI templates generally are difficult to build • Well constructed templates have the ability to remind physicians of certain questions that should be asked

13. HPIs and EHRs (2) • HPI templates continued: • Must take into consideration: • Clinical knowledge to aid with documentation • Medicolegal considerations • Were all the relevant questions asked and documented in case the care of the patient was to later be challenged • Coding and billing questions • Needs to code for the HPI elements (duration, location, severity, quality, modifying factors, context, associated signs and symptoms and timing) • Alternative is to have capacity to recognize when three chronic conditions and their statuses are documented

14. HPIs and EHRs (3) • Template models vary widely between EHR systems • Usually context specific • E.g., New patient headache, follow-up diabetes, etc. • Usually specialty specific • Very different level of detail may be needed depending on specialty

15. Past Medical, Family and Social History • Often the next section of the history and physical (H&P) after HPI • May be entered by the patient, taken by the MA, or in some cases imported electronically • Typically reviewed by the provider before they see the patient • Provider will use information from the section to help with determining the diagnosis

16. Past Medical History • Often obtained prior to the patient being seen by the provider and reviewed by the provider before seeing the patient • Complete history, regardless of relevancy • Can be labor intensive for patient/staff to record • Past medical history usually contains: • Medications • Allergies • Current and former illnesses and injuries • Surgeries • Hospitalizations • Immunization history • Birth history • Others

17. Problem List • Was a separate sheet in the front of paper chart, used in inpatient records and in some specialties • Has evolved with advent of EHRs to be central component of patient record • Generally a subset of information from the past medical history, limited to relevant conditions that are currently active • Use varies markedly • Central focus of interoperability efforts via CCD

18. Past Family History • Can be limited to a screening history of relevant medical conditions in the patient’s family history • Weighted towards conditions that have known tendency to be passed from one generation to another • E.g., Huntington’s Disease • Can have less relevance in elderly patients • Will take on a great deal of new significance in the genomic medicine era

19. Social History • Usually includes: • Occupation • Marital history • Living situation • Family members when relevant • Relationships when relevant • Alcohol use • Drug use • Sexual history • Other social factors

20. Provider Considerations for PFSH • Make sure all relevant information is obtained • Make sure items that could adversely impact patient care are captured • Medicolegal considerations (e.g., missed drug allergy) • Important for decision support applications, like e-prescribing CDS tools • Needs to be placed into correct sections of EHR to be used for E&M coding • All three needed for highest coding levels • Avoid defaults that bring in too much information and falsely elevate coding levels

21. HIT Considerations for the PFSH • As compared to the HPI, this section is much more easily “codified” • More applicable to interoperability • Medications, problems (usually selected items from the past medical history), allergies and labs are now shared via CCD • EHRs and other HIT systems have limited capabilities to import and export this data, but this is rapidly evolving

22. HIT Considerations for the PSFH • Importing data directly from an HIE or other source needs to be done carefully • Data can be corrupted • E.g., wrong code used and then interpreted incorrectly by receiving system • Incomplete or inaccurate data can impact patient care • Negation can corrupt data • Uncertainty can corrupt data • Data integrity is a rapidly emerging area of HIT

23. HIT Considerations for PSFH (3) • EHR • May provide templates • May require specialty specific templates • E.g., details of prior surgeries for surgical subspecialty like orthopedics • Data may be codified at point of capture • ICD-9-CM in most cases • CPT in some instances • SNOMED CT emerging • May need to interact with an immunization module, and state registries

24. Review of Systems • Inventory of current body systems • Basically a screen following the HPI and PFSH to identify any other symptoms or patient identified findings that were not previously addressed in HPI • Typically about 14 systems are used • E.g., respiratory system, cardiovascular system, etc.

25. Review of Systems (2) • Labor intensive • Can lead to discovery of new information that could markedly impact diagnosis and care decisions • Can also be a time intensive pursuit of information that is not relevant for that specific encounter • Questions like “are you experiencing fatigue” are potentially going to yield a high percentage of positive responses that the provider may feel obligated to pursue….

26. Review of Systems (3) • What is the provider thinking? • Don’t miss anything relevant that could impact the care of the patient • Patient care concerns • Medicolegal concerns • EHRs allow for default normals or cloning in ROS; common to see conflicts with HPI • Get the information needed to justify the level of service (e.g., E&M code) • Obtain and document the information as efficiently as possible, i.e., avoid having this take away from time spend in other areas of the encounter

27. Review of Systems (4) • EHR considerations • ROScan be a major workflow consideration • Patients can enter the data • Via kiosk, patient portal, personal health record, forms that can be scanned, etc. • May need to translate medical information to something patients can consume • MA or other ancillary staff can enter data provided by patients in writing, or taken directly from the patient • Provider may take the ROS, but in general they review information entered by others • Tendency for fraud relatively high in this section due to lack of interaction with HPI • Common for finding in HPI to be in conflict with ROS • Suggests fraud given that ROS defaults are common settings in EHRs

28. Physical Examination • Typically includes • Measured vital signs: height, weight, blood pressure, pulse, respirations • BMI is calculated • Direct observations of the patient (e.g., skin lesion on face) • Findings on inspection of the patient (e.g., tenderness of the abdomen) • Some test results may be included in the PE (e.g., smear of fluids obtained during procedure)

29. Physical Examination (2) • Can be very specialty specific • Usually area of body targeted is based on the patient’s presenting complaints • “Full” physical could take 2 hours or more to complete • Very data intensive for abnormal findings • Many clinical examination findings have multiple ways of being described • Eponyms used frequently

30. Physical Examination (3) • What is the provider thinking? • Don’t miss something that could make a difference in the patient’s care • Perform an adequate examination of the relevant organ system, and document it, to demonstrate the standard of care was met • Document findings in organs system that were medically relevant to examine and captured for level of service (E&M) determination (i.e., how much you should be paid)

31. EHR Considerations for PE • Massive amounts of content needed • Large templates • Coding rules very complicated in E&M guidelines • 1995 Guidelines nebulous • 1997 Guidelines very specific and specialty appropriate – Used by most EHRs • Ideal for computational assistance • Frequently cited reason why providers purchase an EHR, i.e., to code visits more accurately • Defaults for normal examinations are faster than dictating, however normal defaults have to be used cautiously.. • E.g., normal lower extremities documented in a patient who has a leg amputation • The government is watching…. • Pulling forward a prior examination can be very efficient, but needs to be done with caution • Providers need to review each character on the screen and take ownership

32. Labs, Test Results and Procedures • Often placed in the clinical record between physical and assessment • May be in other locations such as the HPI, assessment or plan • Includes: • Lab values obtained prior to or during the visit • Radiology findings obtained prior to or during the visit • Other test results (e.g., exercise treadmill test) • Reports from other providers • Procedures performed as part of the encounter • E.g., draining fluid from a knee

33. Provider Considerations (Labs, etc.) • What is the provider thinking? • Quickly assemble all relevant information to help with making the diagnosis and treatment plan • Don’t miss something relevant that would be considered part of the standard of care • Capture the fact that the information was reviewed for reimbursement (E&M) purposes • Enter the information efficiently

34. EHR Considerations • EHR may or may not have ability to import lab and other information of this nature into H&P note • For example, a PACS system may allow import of radiology results) • Often will not have ability to capture this as information relevant to E&M coding • Point system is used when providers look at test results, look at actual images, etc. • Need to be documented but can influence level of complexity of visit • May not have ability to template the procedure, which are the most straightforward types of encounters to document in EHRs

35. Assessment • Provider pulls together all relevant information and often creates a “differential diagnosis” • Differential diagnosis is a weighted list of potential diagnoses • Ranked based on • Potential urgency • Can the problem be treated • What is the most likely underlying disease • What else needs to be considered? • “Zebras”

36. Provider Considerations • What is the provider thinking? • Demonstrate that all relevant diagnoses, based on clinical relevance, have been considered • Demonstrate thought process behind conclusions • Demonstrate level of knowledge to other providers (in particular for specialists) • Demonstrate that the patient has been made fully informed regarding their condition

37. EHR Considerations • Create tools that assist with diagnosis • Clinical Decision Support (CDS) • List of alternative diagnoses to consider • Access to knowledge resources • Import diagnoses from other sections of the record • Modify diagnoses • Need to choose ICD-9/10 codes that are needed for billing of the encounter • Justify complexity of visit through description of patient’s problem and potential risks to their future health, and the risk of interventions

38. Plan • Includes • Diagnostic tests • Treatments • Medications • Surgeries • Therapy • Others • Patient instructions • Follow-up care • Return visits • Referrals to other providers

39. Plan (2) • What is the provider thinking? • Prescribe medications where risk is offset by potential benefit • Fully inform patient of potential risks • Order tests that confirm diagnosis or eliminate diagnoses under consideration • Refer patients as appropriate to other care provider such as specialists • Follow a plan of care that would be consistent with the standard of care • Patient education and counseling of particular importance • Capture information that will be used for level of service (E&M)

40. EHR Considerations • Interact with data entered in other sections of record to assist provider with management • CDS (e.g., medication contraindications) • Standards of care for specific conditions • E.g., correct antibiotic to use • Capture what was discussed with the patient • Macros, templates, free text or VR often used • Present provider with coding summary, including level of service (E&M) coding assistance tools • Allow provider to close note and send relevant information to a billing tool.

41. Thank You • Any questions? • Contact information • Email address: mcjstearns@gmail.com