What is your background and how did you first become interested in Patient PreHistory?
As a caregiver, I saw a dramatic difference between what occurred during a medical encounter versus what was documented in the medical record. It is easy to blame the provider for not documenting all of the details, but is it really reasonable to expect the medical provider to be a skilled stenographer? As a certified professional coder and medical auditor, it makes sense to me to allow the patient to answer the near 30 history questions as defined and structured by the Centers for Medicare and Medicaid Services (CMS).
To support the patient’s federal right to amend and access the record, nonprofit Patient Advocacy Initiatives was formed in 2015. That same year, we conducted clinical research to validate a patient authored PreHx and the resulting patient co-authoring of the medical record.
As a physician, I am driven to help improve the patient experience and the medical provider experience. Our transition from paper to electronic health records has placed a high amount of administrative burden and computer tasks on providers that distracts from the patient in the room. I believe patient co-authoring of the history, with the use of a PreHx, can allow the patient and provider to work together to efficiently gather information. I believe, as our research showed, that this type of cooperative partnership between patients and providers results in better care.
Your nonprofit promotes the patient use of a PreHistory (PreHx) in preparation for a medical encounter. How could this improve healthcare?
Patients and providers are put in a near impossible position during a medical encounter. 1995 and 1997 CMS Evaluation and Management Documentation Guidelines have defined and structured about 30 questions to comprise a history. During the time constraints of a 15-minute office schedule, a medical provider does not have time to ask each question, wait for a response, and then type/dictate answers into the computer. Our PreHx is a replica of all of the history questions in the E/M Guidelines. By completing a PreHx at home, the patient can consider each question, reflect and produce an appropriate answer. This helps prepare the patient for the visit and also supplies answers for the medical provider.
Your PreHx is designed to allow the patient to co-author the medical record. Is this legal?
Yes, it is legal per multiple laws. The Standards for Privacy of Individually Identifiable Health Information of 2001, also known as the HIPAA Privacy Rule, grants patients the right to request to amend their health record [45 C.F.R § 164.526]. A patient can submit a PreHx as a written request to amend the health record. From the medical provider point of view, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) gives credit to providers who accept patient-generated health data (PGHD). Our government includes a patient-authored history as a form of PGHD.
How can parents or caregivers help document an accurate PreHx for children who are not old enough to write one themselves?
A patient or caregiver can ask a child the PreHx questions and enter the responses. PreHx questions, reflective of the official CMS history, ask basic questions, such as: “What makes your problem better or worse?” (modifying factors) and “Where is your problem located on the body?” (location). A small child with an ear infection may answer: “My right ear.” To what makes it better or worse, the child may answer: “Nothing.”
If the child is an infant, he or she may not yet be verbal. In this case, the parent can author the PreHx: “Tugging on right ear” (location), “Less crying after dose of Tylenol, more crying if right ear is touched” (modifying factors).
Both our paper and digital PreHx’s offer examples to help formulate answers. The main objective is to help your medical provider assemble all of the information so time spent at a medical encounter can be directed more toward examination and medical decision making, rather than dominated by basic information gathering and data entry.
