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Original Contribution  |   February 2017
Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law
Author Notes
  • From Patient Advocacy Initiatives (Drs M.J. Warner and M.K. Warner) and Conemaugh Memorial Medical System (Mr Simunich and Mr Dado) in Johnstown, Pennsylvania. 
  •  *Address correspondence to Michael J. Warner, DO, CPC, Patient Advocacy Initiatives, 130 Jennie Ln, Johnstown, PA 15904-1200. E-mail: drmichaelwarner@patientadvocacyinitiatives.org
     
Article Information
Practice Management / Professional Issues
Original Contribution   |   February 2017
Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law
The Journal of the American Osteopathic Association, February 2017, Vol. 117, 78-84. doi:10.7556/jaoa.2017.018
The Journal of the American Osteopathic Association, February 2017, Vol. 117, 78-84. doi:10.7556/jaoa.2017.018
Web of Science® Times Cited: 1
Abstract

Context: Although federal law grants patients the right to view and amend their medical records, few studies have proposed a process for patients to coauthor their subjective history in their medical record. Allowing patients to fully disclose and document their medical history is an important step to improve the diagnostic process.

Objective: To evaluate patients’ office experience before and after they authored their subjective medical history for the electronic health record.

Methods: Patients were mailed a prehistory form and presurvey to be completed before their family medicine office visit. On arrival to the office, the prehistory form was scanned into the electronic health record while the content was transcribed by hospital staff into the appropriate fields in the history component of the encounter note. Postsurveys were given to patients to be completed after their visit. Pre- and postsurveys measured the patients’ perception of office visit quality as well as completeness and accuracy of their electronic health record documentation before and after their appointment. Medical staff surveys were collected weekly to measure the staff’s viewpoint of the federal law that allows patients to view and amend their medical records.

Results: Of 405 patients who were asked to participate, 263 patients aged 14 to 94 years completed a presurvey and a prehistory form. Of those 263 patients, 134 completed a postsurvey. The pre- and postsurveys showed improved patient satisfaction with the office visit and high scores for documentation accuracy and completeness. Before filling out the prehistory form, 116 of 249 patients (46.6%) agreed or strongly agreed that they felt more empowered in their health care by completing the prehistory form compared with 110 of 131 (84.0%) who agreed or strongly agreed after the visit (P<.001). Staff members agreed that patients should have the right to view and amend their medical records in accordance with federal law.

Conclusion: Empowering patients to contribute subjective information to their electronic health record has the potential to improve the diagnostic process. When conducting a medical encounter, the authors recommend having patients complete a prehistory form beforehand to improve the patient experience while accommodating federal law.

Keywords: electronic health record, diagnostic errors, patient-authored history, prehistory

According to Improving Diagnosis in Health Care (Quality Chasm)1 the latest of a series by the Health and Medicine Division in the National Academies of Science, Engineering, and Medicine (previously the Institute of Medicine), most people in the United States will experience at least 1 diagnostic error, sometimes with devastating consequences. Diagnostic errors and problems with the diagnostic process account for 10% of patient deaths in the United States.1 The authors cite improvement of the diagnostic process as “a moral, professional, and public health imperative.”1(p2) As part of the solution, the report recommends participation of patients and family members to improve the diagnostic process and to reduce errors.1(pp358-363) Family members may spend continuous time with patients and are aware of circumstances that should be communicated to health care professionals. 
Patients have a federal right to view and amend their medical records.2,3 Compliance with the Standards for Privacy of Individually Identifiable Health Information (ie, the Privacy Rule) by health care professionals was required as of April 14, 2002, and is a final rule of the Health Insurance Portability and Accountability Act of 1996.4 Health care professionals must accommodate or respond to a patient’s request to amend his or her medical record within 60 days or face a potential violation. Health care professionals may either make the amendment or offer a written explanation to the patient as to why the task could not be completed. The US Department of Health and Human Services’ Office for Civil Rights is responsible for enforcement, which includes complaint investigations and compliance reviews. That office can assign civil money penalties and criminal prosecution. A government online complaint portal (https://ocrportal.hhs.gov/ocr) and toll-free telephone support (1-800-368-1019) exist to receive complaints and initiate investigations. 
The intent of the Privacy Rule was to give patients the ability to view their medical record to ensure accuracy. With electronic health record (EHR) patient portals and portable computer devices, patients can more easily access such information. Although federal law gave patients the right to amend and view their medical records more than a decade ago, few patients work with health care professionals to input information. We believe that the traditional verbal question-and-answer format of a patient history limits the diagnostic process. As a solution, we implemented a patient-completed prehistory form at a family medicine practice in a small Pennsylvania town. 
The present study was designed to allow for patient and family member participation in the diagnostic process to improve the accuracy and content of the patient’s subjective story. We invited patients to coauthor the history component of their EHR using a prehistory form, which includes the same information in the history note required for documentation. Beyond diagnostic accuracy, we focused on patients’ experiences about contributing to their medical record. We hypothesized that patients would be most satisfied with the documentation of their medical stories if they had an opportunity to write the information themselves. We also measured staff members’ understanding of federal law and attitudes toward the prehistory form. 
Methods
An invitation packet was mailed to patients 1 week before their office visit with the physician (M.J.W.) from mid-March to mid-May 2015. Patients who had a scheduled visit a week before the prehistory packet was mailed were included. No exclusion criteria were used. The physician’s schedule was not altered to accommodate this study. Patients were typically scheduled for a 15-minute visit, with a maximum of 3 patients per hour. Participation was voluntary, and patients were not compensated in any manner for their participation. The institutional review board at Conemaugh Memorial Medical Center approved this study. 
The packet included an invitation letter, a blank paper prehistory form, 2 sample prehistory forms, and a presurvey. Each sample prehistory form described 1 of 2 vignettes: new problem and status of chronic disease. Whether they had 1 or many new or chronic problems, patients were instructed to complete the prehistory form to take with them to their upcoming appointment. 
The welcome packet encouraged patients to have a family member or friend help them to the complete the form. The prehistory form requested the same history information required for documentation by the Centers for Medicare and Medicaid Services5 and is available free of charge.6 
The 3-page prehistory form included blank lines for patients to write responses. Chief complaint, status of chronic disease(s), history of present illness, and family social history were listed. The history of present illness was further divided into 8 components: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. Short descriptors help define components, such as “where on body?” for location and “how long has it been occurring?” for duration. The prehistory form also allowed for a 14-system query for review of systems. 
The presurvey asked patients to answer 7 survey items regarding their perceptions of satisfaction, self-empowerment, appreciation, and the extent to which they felt better heard and understood. Satisfaction was rated on a 10-point Likert-type scale, with 0 indicating not satisfied at all and 10 indicating very satisfied. The remaining perceptions used a 5-point Likert scale, with 1 indicating strongly agree and 5 indicating strongly disagree. 
Office visits began with the submission of the prehistory form and the presurvey. Staff members were instructed to scan the prehistory form into the EHR and title the document as “PreHx.” The content was entered into the history component of the medical encounter note exactly as written by the patient. Every part of the prehistory form had a correlating location in the history component of the encounter note in the EHR. All prehistory forms were shredded after they were scanned into the EHR and information was entered. 
After transcription, the physician entered the examination room and greeted the patient. After reviewing the patient-authored history in the EHR, the physician asked additional questions and conducted a pertinent examination, followed by medical decision making. 
At the conclusion of the office visit, each patient was given a printed copy of his or her encounter note and a 9-question postsurvey. In the postsurvey, patients were asked about their office note, perceptions of satisfaction, self-empowerment, appreciation, and the extent to which they felt better heard and understood. Patients were instructed to first read the encounter note, complete the postsurvey, and mail the survey anonymously to our office. Completed postsurveys were placed in a secured box and collected weekly. This study required the physician to complete the encounter note at the time of service so that patients could receive a printed copy of the note at the end of the visit. 
Staff members (comprising an osteopathic family physician, a registered nurse, a licensed practical nurse, 2 medical assistants, and 2 medical secretaries) were distributed a 7-question survey by hand at the beginning of the 2-month study, at the end of every week during the study, and at the conclusion of the study. The 7-question survey asked staff members about their duties and understanding of the federal law and attitudes toward the prehistory form. These surveys allowed them to express their views regarding patient participation in the EHR review and amendment process. Each staff member had an opportunity to identify him- or herself as having roles either at the welcome window, triage station, or check-out window or as a physician. After staff members completed the survey anonymously, the surveys were placed in a secure box. 
Results
Of 405 patients who were asked to participate, 263 (64.9%) returned the prehistory forms. Of 263 patients, 152 (57.8%) were men, and 100 (38.0%) were women. Eleven patients did not report their sex. The patients’ ages ranged from 14 years to 94 years. Three patients were younger than 18 years. The mean age of men was 64 years, and the mean age of women was 63 years. No statistically significant difference was found based on age by sex using independent samples t test (P=.665). No response bias on the basis of sex was found. 
Overall, 263 of 405 patients (64.9%) returned the presurvey, and 134 of those 263 (51.0%) returned the postsurvey. Patients anonymously completed the pre- and postsurveys. The average response rate per question for the 9-question postsurvey was 52%. 
After adjusting the overall α=.05 with a Bonferroni correction to yield a testwise α=.0125, the change in response regarding empowerment, appreciation, and being understood were found to be statistically significant using an independent sample t test on the mean and the Mann-Whitney U test on the response distribution (P<.005). 
Patients felt more empowered in their health care by completing the prehistory form (Table). Overall, 116 of 249 patients (46.6%) answered “agree” or “strongly agree” before filling out the prehistory form compared with 110 of 131 (84.0%) after the visit (P<.001). Additionally, 167 of 260 patients (64.2%) demonstrated a greater appreciation of their chance to coauthor their EHR compared with 116 of 132 (87.9%) after the visit (P<.001). In total, 145 of 254 patients (57.1%) felt that submitting a prehistory form allowed them to be better heard and understood compared with 112 of 131 (85.5%) after the visit (P<.001). Not all patients answered every question. 
Table.
Patients’ Pre- and Postsurvey Responses About the Prehistory Forma
Survey Item Likert Scaleb Time Point N Mean Difference in Means (Post–Pre) Percent Change (Post–Pre)/Pre P Value
How satisfied were you with your experience as a patient in this office? 0-10 Pre
Post
225
134
9.5
9.7
0.2, improved 2% .048c,d
Completing the prehistory form made me feel more empowered in my health care. 1-5 Pre
Post
249
131
2.5
2.0
–0.5, improved –20% <.001c,d
I appreciate being given the chance to coauthor my medical record. 1-5 Pre
Post
260
132
2.2
1.8
–0.4, improved –18% <.001c
I feel that I will be better heard and understood by having submitted a prehistory. 1-5 Pre
Post
254
131
2.4
1.9
–0.5, improved –21% <.001c,d

a The presurvey was completed at the time that the prehistory form was completed and collected at presentation to the office. The postsurvey was distributed after the office visit and mailed to the office.

b Satisfaction was rated on a 10-point Likert-type scale, with 0 indicating not satisfied at all and 10 indicating very satisfied. The remaining perceptions used a 5-point Likert scale, with 1 indicating strongly agree and 5 indicating strongly disagree.

c Some violation of normality assumption.

d Unequal variances assumed.

Table.
Patients’ Pre- and Postsurvey Responses About the Prehistory Forma
Survey Item Likert Scaleb Time Point N Mean Difference in Means (Post–Pre) Percent Change (Post–Pre)/Pre P Value
How satisfied were you with your experience as a patient in this office? 0-10 Pre
Post
225
134
9.5
9.7
0.2, improved 2% .048c,d
Completing the prehistory form made me feel more empowered in my health care. 1-5 Pre
Post
249
131
2.5
2.0
–0.5, improved –20% <.001c,d
I appreciate being given the chance to coauthor my medical record. 1-5 Pre
Post
260
132
2.2
1.8
–0.4, improved –18% <.001c
I feel that I will be better heard and understood by having submitted a prehistory. 1-5 Pre
Post
254
131
2.4
1.9
–0.5, improved –21% <.001c,d

a The presurvey was completed at the time that the prehistory form was completed and collected at presentation to the office. The postsurvey was distributed after the office visit and mailed to the office.

b Satisfaction was rated on a 10-point Likert-type scale, with 0 indicating not satisfied at all and 10 indicating very satisfied. The remaining perceptions used a 5-point Likert scale, with 1 indicating strongly agree and 5 indicating strongly disagree.

c Some violation of normality assumption.

d Unequal variances assumed.

×
Eighty-two comments were written on 82 patient pre- and postsurveys. When asked about their views on patient participation in the EHR review and amendment process, 1 patient wrote that he or she did not want to fill out any more forms. Three patients wrote that there was little need to complete such a form because they trusted their physician. Overall, patients exhibited support for the opportunity to contribute to their EHR. This sentiment increased after the visit and after viewing their encounter note. One patient wrote: “I loved completing the PreHx. It gave me time to reflect on the questions and answer them without rushing.” Several patients remarked that they often forgot to ask questions at previous office visits but were able to address all their concerns with the prehistory form. Patients’ comments supported the belief that because of the prehistory form, physicians were able to spend more time focusing on their needs during office visits. They also said that the visit seemed longer and more directed toward their concerns. Patient scores were mixed as to whether they wanted to access their medical records online. Some patients expressed a mistrust of EHR security. 
The staff survey results revealed that all staff members agreed that patients are allowed to view and amend their medical record according to federal law and concurred with the idea and practice of patients’ coauthorship of their medical records. Although the strength of their agreement improved throughout the study, the change was not statistically significant. In the comment section of the survey, the staff noted that they believed the prehistory form should be an automated feature of the patient portal. 
The physician felt that by reading the patient-authored history, he better understood his patients’ problems and concerns. He wrote, “Once I read the PreHx, it was as if we had already been talking for fifteen minutes. Data from the PreHx allowed me to ask more specific questions. Because patients actively engaged in their care, they were better able to participate in shared decision-making.” 
Discussion
Sir William Olser said, “Listen to the patient, he is telling you the diagnosis.”7 Despite advances in modern medicine, experts rate the conversation between patient and physician as more important than either the physical examination or laboratory investigations to make an accurate diagnosis.8 
Traditional history taking has deficits related to completeness and time required by the physician to obtain and document information.9 The history should include as much detail as required to retell the story,10 but 77% of physician-generated interviews fail to fully elicit and document their patients’ reasons for visiting the physician.6(p10) In light of EHRs with templates and copy-forward functions, some histories contain information that is incomplete, inappropriate, fraudulent, or “downright factitious.”10-12 
Medical narratives tend to neglect or objectify the patient’s subjective experience, including symptoms.13 Although it is the responsibility of the physician to translate “lay” narrative into medical constructs, physicians must avoid misinterpretation or alteration of the patients’ actual experience.6(p102),14 Changing vomiting blood in the history to hematemesis converts the vernacular into medical terminology but strips away the patient’s perspective. The current study preserved the subjective experience by using and emphasizing the patients’ words. 
Medical questionnaires have been studied as an adjunct to physician interviews with patients. In 1949, the Cornell Medical Index was found to be a quick and reliable method of obtaining patient information.15 Written or computer-automated questionnaires were also found to be more accurate and complete than traditional physician history taking.7 
Although we did not measure time as a factor in the current study, we did maintain a 15-minute visit schedule. We believe that less time was spent discussing medical history, which allowed for deeper questioning and more shared decision making. 
Allowing patients to tell their story and have it documented in the EHR gives respect to the patient. The process of accommodating a patient’s right to amend and view the entire medical record speaks to medical core competencies,16 including patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. 
Patient participation in the medical record extends the moral obligation to improve the diagnostic process beyond health care professionals to patient responsibility, obligation, and duty to assume an active role in health care. We envision an evolution of the patients’ role as consumers of health care. 
The Medicare Access and CHIP Reauthorization Act calls for patient-generated health data as part of the objective to coordinate care through patient engagement.17 By accommodating a patient-authored history, the current study demonstrates a process that achieves this objective. 
The current study recognized the patients’ prehistory form as a written request to amend the medical record. Although the law permits 60 days to approve or deny an amendment, the current study allowed for immediate acceptance. In addition to scanning the prehistory form into the EHR, we entered the patients’ narrative into the history component of the encounter note to be shared with all current and future health care professionals. We believe that a strong history will result in an improved diagnostic process. 
The Health and Medicine Division report1 validates the attainability of solutions to the diagnostic process. This view bolsters our belief, therefore, that all health care professionals should be able to accommodate their patients’ self-authored history. We encourage EHR systems to include a prehistory note as part of every patient portal to allow patients to participate interactively with their medical records and freely address their subjective concerns. 
In Improving Diagnosis in Health Care (Quality Chasm),1(pxiii) physicians are called to view patients as central to minimizing diagnostic errors. We recognize the patient’s voice as a missing piece of the medical record and remedied it with a patient-authored history. We joined the patient and the physician together in a partnership in health care. Rather than call for new rules, the present study followed federal laws and facilitated patients’ active participation. 
Limitations
In the current study, we used paper forms because paper is inexpensive and easily mailed. If we had an electronic version built into the EHR patient portal, staff members could avoid potentially introducing errors by scanning the document and transcribing the information. 
All patient pre- and postsurveys were aggregated. We could have linked each patient’s surveys together by embedding barcodes into the documents to produce more accurate statistical information, but we chose not to because of the potential perception of privacy loss and the cost of logistical management. 
The present study did not assess the educational or literacy level of our patients. Some patients may not have participated because of illiteracy. Some patients completed the prehistory form with the help of a family member or friend. Further exploration will likely identify ways to promote family and friend participation, per the Health and Medicine Division’s recommendations.1 
The current study did not film the face-to-face encounters to compare prehistory vs nonprehistory visits. Analysis of such encounters would likely reveal deficits and opportunities for improving the diagnostic process. 
Conclusion
Patients have a federal right to view and amend their medical records. Allowing patients to complete a prehistory form and incorporating the information into their medical record resulted in high scores for documentation, along with greater patient satisfaction with the medical encounter. We believe this type of patient participation has the potential to improve EHR content and accuracy, as well as the diagnostic process. Completing a prehistory form enabled patients to feel empowered in their health care. We recommend the use of a patient-authored history as a practical and effective means of documenting patients’ stories and encouraging them to become active consumers of health care. 
References
Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care (Quality Chasm). Washington DC: National Academies Press; 2015.
Access of Individuals to Protected Health Information, 45 CFR §164.524 (2002).
Amendment of Protected Health Information, 45 CFR §164.526 (2002).
Compliance Dates for Initial Implementation of the Privacy Standards, 45 CFR §164.534 (2002).
Department of Health and Human Services, Centers for Medicare & Medicaid Services. Evaluation and management services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Updated August 2016. Accessed December 2, 2016.
Welcome to Patient Advocacy Initiatives. Patient Advocacy Initiatives website. http://patientadvocacyinitiatives.org. Accessed December 2, 2016.
Silverman ME, Murray TJ, Bryan CS. The Quotable Osler. Philadelphia, PA: American College of Physicians; 2008:98.
Cole SA, Bird J. The Medical Interview: The Three Function Approach. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2014:9.
Bachman JW. The patient-computer interview: a neglected tool that can aid the clinician. Mayo Clin Proc. 2003;78:67-78. [CrossRef] [PubMed]
Kuhn T, Basch P, Barr M, Yackel T; Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162(4):301-303. doi:10.7326/M14-2128 [CrossRef] [PubMed]
Zakim D, Braun N, Fritz P, Alscher MD. Underutilization of information and knowledge in everyday medical practice: evaluation of a computer-based solution. BMC Med Inform Decis Mak. 2008;8:50. doi:10.1186/1472-6947-8-50 [CrossRef] [PubMed]
Skolnik N, Notte C. Whispered pectoriloquy. Family Practice News. August 4, 2015.
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Larsen JH, Neighbour R. Five cards: a simple guide to beginning the consultation. Br J Gen Pract. 2014;64(620):150-151. doi:10.3399/bjgp14X677662 [CrossRef] [PubMed]
Brodman K, Erdman AJJr, Lorge I, Wolff HG, Broadbent TH. The Cornell medical index; an adjunct to medical interview. JAMA. 1949;140(6):530-534. [CrossRef]
American Association of Colleges of Osteopathic Medicine (AACOM). Osteopathic Core Competencies for Medical Students. Chevy Chase, MD: AACOM; August 2012. https://www.aacom.org/docs/default-source/core-competencies/corecompetencyreport2012.pdf?sfvrsn=4. Accessed December 19, 2016.
Medicare program; merit-based incentive payment system (MIPS) and alternative payment model (APM) incentive under the physician fee schedule, and criteria for physician-focused payment models. Fed Regist. 2016:81;28222-28228.
Table.
Patients’ Pre- and Postsurvey Responses About the Prehistory Forma
Survey Item Likert Scaleb Time Point N Mean Difference in Means (Post–Pre) Percent Change (Post–Pre)/Pre P Value
How satisfied were you with your experience as a patient in this office? 0-10 Pre
Post
225
134
9.5
9.7
0.2, improved 2% .048c,d
Completing the prehistory form made me feel more empowered in my health care. 1-5 Pre
Post
249
131
2.5
2.0
–0.5, improved –20% <.001c,d
I appreciate being given the chance to coauthor my medical record. 1-5 Pre
Post
260
132
2.2
1.8
–0.4, improved –18% <.001c
I feel that I will be better heard and understood by having submitted a prehistory. 1-5 Pre
Post
254
131
2.4
1.9
–0.5, improved –21% <.001c,d

a The presurvey was completed at the time that the prehistory form was completed and collected at presentation to the office. The postsurvey was distributed after the office visit and mailed to the office.

b Satisfaction was rated on a 10-point Likert-type scale, with 0 indicating not satisfied at all and 10 indicating very satisfied. The remaining perceptions used a 5-point Likert scale, with 1 indicating strongly agree and 5 indicating strongly disagree.

c Some violation of normality assumption.

d Unequal variances assumed.

Table.
Patients’ Pre- and Postsurvey Responses About the Prehistory Forma
Survey Item Likert Scaleb Time Point N Mean Difference in Means (Post–Pre) Percent Change (Post–Pre)/Pre P Value
How satisfied were you with your experience as a patient in this office? 0-10 Pre
Post
225
134
9.5
9.7
0.2, improved 2% .048c,d
Completing the prehistory form made me feel more empowered in my health care. 1-5 Pre
Post
249
131
2.5
2.0
–0.5, improved –20% <.001c,d
I appreciate being given the chance to coauthor my medical record. 1-5 Pre
Post
260
132
2.2
1.8
–0.4, improved –18% <.001c
I feel that I will be better heard and understood by having submitted a prehistory. 1-5 Pre
Post
254
131
2.4
1.9
–0.5, improved –21% <.001c,d

a The presurvey was completed at the time that the prehistory form was completed and collected at presentation to the office. The postsurvey was distributed after the office visit and mailed to the office.

b Satisfaction was rated on a 10-point Likert-type scale, with 0 indicating not satisfied at all and 10 indicating very satisfied. The remaining perceptions used a 5-point Likert scale, with 1 indicating strongly agree and 5 indicating strongly disagree.

c Some violation of normality assumption.

d Unequal variances assumed.

×