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Letters to the Editor  |   June 2018
Response
Author Notes
  • Patient Advocacy Initiatives, Johnstown, Pennsylvania 
Article Information
Neuromusculoskeletal Disorders / Ophthalmology and Otolaryngology / Practice Management / Psychiatry
Letters to the Editor   |   June 2018
Response
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 362-364. doi:10.7556/jaoa.2018.078
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 362-364. doi:10.7556/jaoa.2018.078
I thank Dr Wieczorek for her viewpoints regarding the February 2017 study by Warner et al,1 in which patients were given the opportunity to coauthor the history component of their electronic health record (EHR) during a visit with a family physician. Patients participated by completing a 2½-page prehistory form, which replicates the nearly 30 history questions as defined and structured by the Centers for Medicare & Medicaid Services (CMS) Evaluation and Management Documentation Guidelines.2 Our prehistory form, as with CMS history, includes the chief complaint(s), history of present illness, status of chronic condition(s), review of systems, and past family social history. 
Dr Wieczorek cites the relationship escalation model by Mark L. Knapp, PhD, which builds a relationship first with a brief “initiation.”3 She seems to imply that reviewing a patient's written words at the beginning of the office visit circumvents an opportunity for the patient and provider (ie, physicians, nurse practitioners, physician assistants) to come together first with the initiation stage. This was not the case in our clinical study. 
As part of the research protocol, patients were mailed an invitation packet, which included the prehistory form, to their home 1 week before a scheduled office visit. Rather than wait to ask the patient questions in the office, which often catches patients off guard, we encouraged patients to reflect on the questions and provide answers in advance. In addition, we recommended that patients enlist help from family members, friends, and caregivers. 
As the physician in the study, I first greeted the patient when I entered the room. Greeting gestures, often with hugs and small talk, fulfilled Knapp's “initiation” stage. I then read the patient's narrative as documented in the EHR. Rather than starting with the open-ended question, “Why are you here today?”, I was able to read the patient's story and mentally download the patient's concerns as a case in about 30 seconds. I affirmed what I learned by repeating back to the patient, “You tell me this and this are going on?” My response to the patient's words fulfilled “experimenting,” Knapp's second stage of coming together. The final coming together stages in Knapp's relationship model, “intensifying, integrating and bonding,” occurred with a few more history questions, followed by a pertinent examination, assessment, and plan. Because the patient and physician were highly engaged, medical decision-making readily transformed into shared decision-making. 
The purpose of having the individual coauthor the record with a prehistory was to facilitate patient-to-provider communication, reduce the administrative burden, and improve medical record documentation. For example, in a 2017 study, Valikodath et al4 found poor correlation between patients’ reports in a waiting room to what was documented in the EHR moments later. The study invited patients to answer 8 written questions regarding the presence/severity of 8 eye problems while in the waiting room of a university eye center. Researchers collected the forms before patients left the waiting room to see the provider. Investigators compared the patient reports with documentation in the EHR. Regarding the 8 eye concerns, investigators searched the EHR encounter notes for any mention of each patient's concern(s) and found them to be commonly absent. For example, a patient's waiting room concern about eye pain was not documented by the provider 26.5% of the time. If 3 or more concerns were indicated in the waiting room, not 1 medical record in the study accurately captured all of the patient's concerns. 
In accordance with Knapp's model, Valikodath et al4 demonstrated elements of relational maintenance “coming apart” as documentation ignored a substantial amount of patients’ chief complaints. As a certified professional coder, compliance officer, and medical auditor, I wonder about the rest of the medical record. What about the history of present illness, status of chronic conditions, review of systems, and past family social history? 
The use of EHRs has created a default for providers to autopopulate pages of patient information and responses with a few keystrokes. These methods result in detailed medical records that may require extensive editing to match the patient's expressed concerns. Templates and copy-forward functions in the EHR can save time, but if the content has nothing to do with the patient, then inaccurate and potentially harmful information may be created. 
IBM recently ceased the supercomputer Watson's work on a “promise to transform cancer care with the help of artificial intelligence,” at the University of Texas MD Anderson Cancer Center.5 After spending $62 million and 5 years, researchers had “little to show.” Investigators cited Watson's problem “reading relevant information in patient charts.” If documentation in the cancer center's EHRs looked anything like the eye center's EHRs, Watson never had a chance! 
Although it is easy to blame physicians, it is worth considering the current system for gathering patient information. Providers are expected to function in top form, but they are also expected to ask for and record a long list of basic information in the span of a few minutes. The cure is not to discipline or chastise physicians but to free them of burdensome tasks. By allowing patients to complete a prehistory form in preparation for a physician visit, physicians can be freed to practice medicine. 
Regarding Dr Wieczorek's concerns about medical practice efficiency, our research was conducted within a 15-minute office schedule. Other than patients arriving with a completed prehistory form, we had no advanced notice of their participation. Whereas Valikodath et al4 struggled to properly record patients’ chief complaint(s), we efficiently gathered all of the patient's history responses into the medical record before the provider entered the room. Further, all office notes were completed at the end of the visit. At the check-out window after the visit, each patient received a paper copy of the complete encounter note. In addition, patient survey results showed high satisfaction with this process (mean, 97%). Patients appreciated being given the chance to coauthor their medical record and felt better heard and understood. 
Federal laws give patients the right to access and amend their medical record.6 A cultural change is needed to make it commonplace for patients to access and amend their EHRs. 
I foresee EHR documentation improving with the mindset of communication scholars. As patients become more involved in framing their stories and crafting their narratives, communication models such as Knapp's will guide us. For now, however, the US medical system is stuck. The transition from paper medical records to EHRs has eroded communication and displaced providers into overwhelming tasks of stenography and basic data entry. Our current trajectory is not sustainable as medical documentation needs to be accurate and truthful. Our prehistory research shows a process that remedies the integrity of EHR data, improves workflow, and fosters the patient-provider relationship. 
 Disclaimer: Dr Warner is president of Patient Advocacy Initiatives, a 501(c)(3) nonprofit organization that offers free paper and digital prehistory forms as well as free educational material to empower individuals to be their own patient advocate.
 
References
Warner MJ, Simunich TJ, Warner MK, Dado J. Use of patient-authored prehistory to improve patient experiences and accommodate federal law. J Am Osteopath Assoc. 2017;117(2):78-84. doi: 10.7556/jaoa.2017.018 [CrossRef] [PubMed]
Evaluation and Management Services. Washington, DC: US Department of Health and Human Services, Centers for Medicare & Medicaid Services; 2017. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Accessed January 17, 2018.
Knapp's relationship model. Communication Theory website. https://www.communicationtheory.org/knapps-relationship-model/. Accessed January 17, 2018.
Valikodath NG, Newman-Casey PA, Lee PP, Musch DC, Niziol LM, Woodward MA. Agreement of ocular symptom reporting between patient-reported outcomes and medical records, JAMA Ophthalmol. 2017;135(3):225-231. doi: 10.1001/jamaophthalmol.2016.5551 [CrossRef] [PubMed]
Hernandez D. Hospital stumbles in bid to teach a computer to treat cancer: a University of Texas audit shows MD Anderson's struggles to use IBM Watson in a health-care setting. The Wall Street Journal. March 8, 2017.
Standards for Privacy of Individually Identifiable Health Information. Fed Regist. 2000;65(250):82462-82829.