Physician-Patient Encounters

The Physician PerspectiveMichael Stearns, MD, CPC

HIT Consultant

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

High Level Physician Goals

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…

Develop a rapport 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 Credibility with 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

Establish the Reliability of the Patient

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

Prioritize Nature of Visit

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.

Chief Complaint

Basically the story behind the visit 80% of any diagnosis 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

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 (2)

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 (3)

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

History of Present Illness (4)

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

The HPI and EHRs

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 (2)

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

HPIs and EHRs (3)

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, Family and Social 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

Past Medical History

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

Problem List

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

Past Family History

Usually includes:◦ Occupation◦ Marital history◦ Living situation

Family members when relevant Relationships when relevant

◦ Alcohol use◦ Drug use◦ Sexual history◦ Other social factors

Social History

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

Provider Considerations for 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 PFSH

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 the PSFH

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

HIT Considerations for PSFH (3)

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

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 (2)

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 (3)

EHR considerations◦ ROS 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

Review of Systems (4)

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

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 (2)

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)

Physical Examination (3)

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

EHR Considerations for PE

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

Labs, Test Results and Procedures

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

Provider Considerations (Labs, etc.)

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

EHR Considerations

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”

Assessment

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

Provider 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

EHR Considerations

Includes◦ Diagnostic tests◦ Treatments

Medications Surgeries Therapy Others

◦ Patient instructions◦ Follow-up care

Return visits Referrals to other providers

Plan

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)

Plan (2)

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.

EHR Considerations

Any questions?

Contact information

◦ Email address: mcjstearns@gmail.com

Thank You