Physician-Patient Encounters – The Physician Perspective

 

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
• 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

• Polite and professional
• Not too reserved
• Not too friendly
• Appear knowledgeable
• Patient may know more about a disease than you do after, for example, 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

• Be a good listener
• EHRs can interfere with this process
• Demonstrate familiarity with their complaints and ask insightful questions
• Communication in a way they can easily understand, without coming across as patronizing

Establish the Reliability of the Patient

• Need, in some cases to identify how to interpret information you are provided
• Secondary gain such as what may be seen in a disability payment
• 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

• Use the history, physical and the results of diagnostic studies to form an impression of what might be influencing the patient’s health
• Identify potential emergent 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

• 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 wide number of variation as to how this is structured
• Documentation guidelines (for reimbursement) state that a CC must be present, but it can be part of the HPI.

History of Present Illness

• Basically the story behind the visit
• 80% of the diagnosis comes from the HPI
• Iterative 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
• Somewhat algorithmic
• Eliminate some conditions
• Confirm others
• >Gives weighting to certain conditions  over others in many cases
• 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
• Summary of relevant recent events
• Recent hospitalizations
• Recent surgeries
• Prior evaluations by other providers
• Stressors that could influence health
  • E.g., Work-related stress
• 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
• 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
• Medicolegal documentation
  • Demonstrate that the standard of care was met via documentation
  • Be wary of template defaults and cloning of information
• 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

• Enter complex information and overcome natural language challenges
• Free text via voice recognition, typing or other methods one approach
  • Loses structured data
  • May be offset by NLP and automated coding
• Loses structured 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
• Templates 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
• 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

• 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

• 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

• 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

• 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

• Usually includes:
• Occupation
• Marital History
• Living Situation
  • Family members when relevant
• Alcohol Use
• Drug Use
• Sexual History
• Other Social Factors

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

• 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

• 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
• EHR
• May provide templates
• May require specialty specific templates
  • E.g., details of prior surgeries for surgical subspecialty like orthopedics
  • 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
• ICD-9-CM in most cases
• May need to interact with an immunization module, and state registries

 

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.
• 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….
• 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
• EHR considerations
• This can 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

• Typically includes
• Measured vital signs: height, weight, blood pressure, pulse, respirations
• Direct observations
• Findings on inspections
• Some test results may be included (e.g., smear of fluids obtained during procedure)
• Very specialty specific
• Often very much targeted based on patient’s presenting complaints
• “Full” physical could take 2 hours to complete
• Very data intensive for abnormal findings
• May have varying names
• Eponyms used frequently
• 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 determination

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 results and procedures

• Often placed between physical and assessment
• May be in other locations
• Includes:
  • Lab values obtained prior to or during the visit
  • Radiology findings obtained prior to or during the visit
  • Reports from other providers
  • Procedures performed as part of the encounter
    • E.g., draining fluid from a knee

Provider Considerations

• 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 may or may not have ability to import information of this nature into H&P note
• 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

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”

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 Considerations

• Create tools that assist with diagnosis
• CDS
• List of alternative diagnoses to consider
• Access to knowledge resources
• Import diagnoses from other sections of the record
• Modify diagnoses
• Choose codes 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

Plan

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

Author contact information

 

Michael Stearns, MD

HIT Consultant

Email address:  mcjstearns@gmail.com