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Physician-Patient Encounters The Physician Perspective. Michael Stearns, MD, CPC HIT Consultant. 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

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physician patient encounters the physician perspective

Physician-Patient EncountersThe Physician Perspective

Michael Stearns, MD, CPC

HIT Consultant

high level physician goals
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
develop a rapport with the patient
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…
establish credibility with the patient
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…
establish the reliability of the patient
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
prioritize nature of visit
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
chief complaint
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.
history of present illness
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
history of present illness 2
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
history of present illness 3
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
history of present illness 4
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
the hpi and ehrs
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
hpis and ehrs 2
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
hpis and ehrs 3
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
past medical family and social history
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
past medical history
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
problem list
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
past family history
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
social history
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
provider considerations for pfsh
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
hit considerations for the pfsh
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
hit considerations for the psfh
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
hit considerations for psfh 3
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
review of systems
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.
review of systems 2
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….
review of systems 3
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
review of systems 4
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
physical examination
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)
physical examination 2
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
physical examination 3
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)
ehr considerations for pe
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
labs test r esults and procedures
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
provider considerations labs etc
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
ehr considerations
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
  • 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”
provider considerations
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
ehr considerations1
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
  • Includes
    • Diagnostic tests
    • Treatments
      • Medications
      • Surgeries
      • Therapy
      • Others
    • Patient instructions
    • Follow-up care
      • Return visits
      • Referrals to other providers
plan 2
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)
ehr considerations2
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.
thank you
Thank You
  • Any questions?
  • Contact information
    • Email address: